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ADDRESS FOR ALL CORRESPONDENCE: Dr. Meena Chakrabar ti, Editor KJO, Chakrabar ti Eye Care Centre, Kochulloor,Medical College PO, Trivandrum 695 011, Ph-0471-2555530, 2449599 Fax:- 0471-2558530, E-mail: tvm_meenarup@sancharnet.in
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EX- OFFICIO MEMBERS
Dr. R.R. Varma (President)
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ADVISORS
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EDITORIAL BOARD
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KERALA JOURNAL OF OPHTHALMOLOGY
VOL. XXI ISSUE 3 SEPTEMBER 2009
EDITOR
Dr. Meena Chakrabarti
President
Dr. R.R. Varma
Ambikalayam, Warriam Road
Kochi - 682 016
Ph: 0484-2352010 (R)
Mob: 94471 52010
U
KERALA SOCIETY OF OPHTHALMIC SURGEONS(Registered under Societies Registration XXI of 1860. No.387/2003)
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LF Hospital, Angamaly
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Asoka Hospital
South Bazar
Kannur
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Giridhar Eye Institute
Ponneth Temple Road
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Giridhar Eye Institute
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Chakrabarti Eye Care Centre
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Managing Committee Members
Dr. Anthrayose Kakkanat
Dr. Meena Chakrabarti
Executive Committee Members
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Dr. Mohammed Swadique
Malappuram
Dr. Rajesh Radhakrishnan
Palakkad
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Ernakulam
Dr. C.K. Mathew
Alapuzha
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Pathanamthitta
Dr. Seshadrinathan
Kottayam
Dr. S Venugopal
Kollam
Dr. Biju John
Trivandrum
C O N T E N T SKJOEDITORIAL
241 In the Grip of the Python: Medicine’s Dependence on the
Pharmaceutical Industry
Dr. Meena Chakrabarti
MAJOR REVIEW
243 Retinoblastoma
Dr. Mahesh P. Shanmugham
ORIGINAL ARTICLES
248 Ocular Manifestations of Intracranial Space Occupying Lesions –
A Clinical Study
Dr. K.V. Raju, Dr. Anju Abdul Khader
253 Capsulo-Cortical Adhesions (CCA) and Phacoemulsification (PE)
Dr. Arup Chakrabarti, Dr. Sonia Rani John, Dr.Valsa Stephen,
Dr. Meena Chakrabarti
258 Efficacy of Combining Intravitreal Bevacizumab Monotherapy (IVB) with
Panretinal Photocoagulation (PRP) in Early Stages of Neovascular Glaucoma
(NVG)
Dr. Meena Chakrabarti, Dr. Arup Chakrabarti, Dr.Sonia Rani John
264 Ophthalmic Manifestations in Children with Delayed Milestones –
A Clinical Study
Dr. Reena A, Dr. Lekshmy S.R, Dr. Lekshmi H, Dr. Bindu K. Appukuttan
270 An Outcome Analysis of Posterior Capsular Rent (PCR) In the Hands of
A Senior Phaco Surgeon
Dr. Arup Chakrabarti, Dr. Meena Chakrabarti, Dr. Sonia Rani John,
Dr. Valsa Stephen MS DNB
OPHTHALMIC SURGERY
274 Lens Surgery in Marfan’s Syndrome
Dr. Somdutt Prasad
OPHTHALMIC INSTRUMENATION
280 The Eyesi: Ophthalmic Surgical Simulator
Dr. Meena Chakrabarti, Dr. Sonia Rani John, Dr. Arup Chakrabarti
OCULAR PHARMACOLOGY
285 Nepafenac
Dr. Sonia Rani John, Dr. Meena Chakrabarti, Dr. Arup Chakrabarti
289 Recent Advances in The Back of the Eye Drug Delivery
Dr. Meena Chakrabarti
C O N T E N T SKJOCURRENT CONCEPTS
294 Care and Maintenance of Contact Lens – An Overview
Dr. Pravin Tellakula
CASE REPORT
304 A Case Report of Colobomatous RD
Dr. Arya A.R, Dr. Biju John
306 Vasoproliferative Tumour of The Retina – A Case Report
Dr. Tulefa Shafi, Dr. Natasha Radhakrishnan, Dr. Gopal S Pillai,
Dr.Roshan George
COMMUNITY OPHTHALMOLOGY
309 Go Green for a Healthier Life
Dr. Meena Chakrabarti
PHOTO ESSAY
312 Masquerade Syndrome
Dr. Meena Chakrabarti
315 CONSULTATION SECTION
319 OPHTHALMIC HISTORY
321 JOURNAL REVIEW
324 BOOK REVIEW
329 UPCOMING CME
331 PG TEAR SHEET
333 INSTRUCTION TO AUTHORS
EDITORIAL
In the grip of the python:
Medicine’s Dependence on the
Pharmaceutical IndustryEverything has either a price, or it possesses dignity.”1 Professionals should be “independent
of the state or commerce” 2. These are two off-quoted quotes, but there is a lingering doubt in
our minds as to the threat of Commercialism and Professional integrity.
Commercialism is such a threat to the professional ethics of individual physicians that
commercialism is incompatible with medical professionalism. Personal financial choices by
physicians at times violate professional responsibilities and the fundamental ethical pact with
society. 3 The conflict between commercialism and professionalism is precisely about the
appropriate and inappropriate (not legal vs illegal) ways that physicians should make money
and contribute to society. 5 If medicine loses professionalism or the public perceives that
physicians are not behaving as professionals, it is no wonder that medicine will surrender its
influence and status in society. Can the medical profession and, specifically, peer-reviewed
literature survive the challenges posed by the secular culture of commercialism and at the
same time maintain the public trust? 5-7
For both academic institutions and individuals, receiving gifts, meals, books, or free continuing
medical education creates the presumption of bias. The further acceptance of invitations to
join speakers bureaus, to serve on boards, to consult on marketing issues, to receive payments
for enrolling in clinical trials, and to participate in research studies with payment in stock
pushes this presumption of bias into fact.3-12 Other enticements, sometimes for spouses,
sometimes at the request of the physicians themselves, are immoral, and some are illegal.
Those who do not believe this bias exists are denying scientifically established patterns of
human behavior and deceiving themselves. The “rule of reciprocation,” one of the
strongest tenets of human social behavior, holds that we should try to repay what another
person has provided to us.3 The ability of physicians to remain neutral under the present
barrage of industry largesse is questionable.
Companies target academic “key opinion leaders” 13 -16 (a marketing term) to populate
scientific advisory committees, join speakers bureaus that sometimes aggressively promote
drugs or devices, and participate on manuscript writing committees that support industry
marketing themes 16. Although key opinion leaders seem convinced of their own impartiality,
Carl Elliott, a moral philosopher at the University of Minnesota and author of Better Than
Well: American Medicine Meets the American Dream, 17 strongly disagrees with them, as do
their own colleagues. 18 The practice of key opinion leaders consulting with multiple companies
to present the appearance of objectivity is even more misleading 19,20,21
242 Kerala Journal of Ophthalmology Vol. XXI, No. 3
A generation of new physicians has grown up with the mistaken belief that professional values
can be replaced with marketplace values and that medical care is just another economic service.
Financial success has become the dominant standard of measurement or value even for most
academic medical centers. 21 Young professionals are reminded that these commercial activities
were previously considered unprofessional. 5
There is tremendous value in the cooperation between academia and industry, but the
engagement should be at a distance, with both sides maintaining their own standards and
ethical norms. 4 Although academic medicine and the health care industry seem intertwined
at present, the profession needs to be reminded that the goals of the medical profession are
very different from the goals of the commercial industry. We must seek ways to disentangle
the two and not just use “disclosure” as the mechanism to cleanse the system; “reader or
buyer beware” should not be the mantra of a profession 22 - 24.
There are serious questions about the reliability of some of the commercially funded trials,24
raising very significant moral and ethical questions for some physicians and a dilemma for
journals. In reality, it is the physicians who have permitted the pharmaceutical and biotech
industries to manipulate medical science through these financial relationships. 19
Many researchers have delayed publication of their results by several months to allow for
patent application,25 - 29 to protect their scientific lead, or to slow the dissemination of results
that would hurt sales of their sponsor‘s product,19 and in some instances scientists at top
research universities have completely refused to share results with their colleagues.30 The
reporting of trial outcomes is also sometimes incomplete, biased, and inconsistent with
protocols. 31 Published articles, as well as reviews that incorporate them, may therefore be
unreliable and overestimate the benefits of an intervention; meta-analysis simply amplifies
erroneous results and is much less powerful or valuable than assumed. To ensure transparency
and avoid the overbearance of commercial industry, planned clinical trials must be registered
and protocols should be made publicly available prior to trial completion. Many major journals
will not permit submission of clinical studies that have not been registered
Journals are hampered by this assault of commercialism on publishing. The only tools editors
have in their efforts to enforce policies on full financial disclosure or to control excess
commercialism and bias is the instigation of a full investigation following complaints by
informed readers. When this happens, the journal is dedicated to clarifying the situation for
the reader, albeit indirectly, by involving the relevant institutional review board because journals
do not have formal investigative or enforcement functions.
There is reason for hope, however, as resistance begins to mount against commercial influence
in medicine, as evidenced by suggested changes in the relationship between academic
medical centers and industry.16, 32-33 There are also new and influential parallel initiatives from
academic medical centers themselves, and from think tanks addressing continuing medical
education (the education environment is even more permissive in fostering biases than is
publishing).34-37 Time will tell whether professionalism will rein over commercialism in
medicine.
Dr. Meena Chakrabarti MS DO DNB
Editor, KJO
September 2009 Kerala Journal of Ophthalmology 243
M A J O R
REV I EW
RetinoblastomaDr. P. Mahesh Shanmugam DO FRCSEd PhD
Head, Vitreoretinal and Ocular Oncology Services, Sankara Eye Hospitals,
Bangalore
Retinoblastoma occurs in approximately 1 in 14,000-
34,000 live births. 1-3 No predisposition to race, sex or
laterality of the eye is noted. The majority of cases of
retinoblastoma are sporadic (no family history and no
affected family members on ophthalmic examination).
Retinoblastoma occurs as a result of loss of the tumor
suppressor gene located on band 14, on the long arm
of chromosome 13 (13q14). 4,5 In genetically
transmitted disease, the abnormality results in the
development of usually bilateral, multifocal tumors in
relatively younger patients. This deletion also
predisposes these children to other non-ocular tumors
such as osteosarcoma in later stages of life. In contrast,
sporadic tumors occur in older children and tends to
be unifocal and unilateral. However, 10-20% of
unilateral disease can also be genetically transmitted.
The average age at diagnosis of retinoblastoma in
American children is 18 months, and evidence indicates
that Asian children present later than their western
counterparts 1,6-8. Bilateral cases are diagnosed earlier
than unilateral cases. 1,9
Clinical Features
The most common presentation of retinoblastoma is
leukocoria (61-70 %) (Fig 1) and strabismus
(22-48%) 1,10,11.
On fundus examination retinoblastoma appears as a
slightly white, flat, translucent lesion in the sensory
retina (Fig 2).
Moderately advanced lesions may present as unilateral
or bilateral leukocoria (Fig 3).
Fig. 1.-3. Common modes of presentation of retinoblastoma
Fig. 1. Leukocoria
Fig. 2. White, flat, translucent lesion in
sensory retina
Fig. 3. Advanced Leison
244 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Based on the growth pattern, the tumor can be classified
into endophytic, exophytic, mixed (both endophytic and
exophytic) and diffusely infiltrative tumors.
Spontaneous regression of retinoblastoma occurs in
about 1 percent of patients. It is often seen in eyes with
phthisis bulbi and following an episode of severe
inflammation.
Local spread to the orbit, distant metastasis to brain,
spinal cord, skull bones, distant bones, viscera and
lymph nodes may occur in advanced retinoblastoma.
On ocular ultrasonography retinoblastoma appears as
an irregular mass lesion with high surface reflectivity
and high internal reflectivity resulting in orbital
shadowing all due to the presence of calcium.
Computerized tomography and magnetic resonance
imaging allow detection of extraocular disease,
intracranial metastasis and pinealoblastoma.
Retinoblastoma appears as an intraocular mass with
calcium on CT scan; it appears as a hyperintense to
vitreous lesion in T1 weighted image and hypointense
to vitreous in T2 weighted images on MRI. (Fig 4)
be well differentiated or poorly differentiated. Poorly
differentiated retinoblastoma consists of small to
medium-sized round cells with hyperchromatic nuclei
and scanty cytoplasm. High mitotic figures are often
observed. A well-differentiated tumor may show:
(i) rosettes, or (ii) fleurettes. Seventy percent of
retinoblastomas are known to contain rosettes.
Rosettes are of two types:
Flexner-Wintersteiner rosette
Homer-Wright rosette
In a Flexner-Wintersteiner rosette, columnar cells
are arranged around a clear central lumen. The nuclei
of the cells are arranged near the base of the tumor.
The lumen contains hyaluronidase resistant
glycosaminoglycans, which are found between
photoreceptor and retinal pigment epithelium.
In a Homer-Wright rosette, the cells are arranged
radially around a central tangle of neural fibers.
Fleurettes represent further differentiation and present
as flower bouquet-like aggregates of tumor cells with
bulbous eosinophilic processes projecting through the
fenestrated membrane. They are seen in 6-10 percent
of the retinoblastoma cases.
Differentiation of the tumor does not have prognostic value.
Management
Management options in retinoblastoma include
enucleation, in an eye without visual potential, if more
than half the globe is involved by the tumor, or in the
presence of glaucoma and anterior chamber
involvement. Eyes with visual potential (unilateral/
bilateral cases) are managed conservatively
with modalities that include cryotherapy, laser
photocoagulation, transpupillary thermotherapy (TTT),
thermochemotherapy, chemoreduction, plaque
brachytherapy and external beam radiotherapy1,13.
International classification of
retinoblastoma 14:
As early classifications were deemed insufficient in this
era of chemoreduction of retinoblastoma, a new revised
classification has been devised to offer prognosis of the
affected eye.14
Rarely cytology by fine needle aspiration biopsy may
be necessary to confirm the diagnosis.
In advanced cases with extraocular disease, metastatic
work-up that includes lumbar puncture, CT / MRI scan,
bone marrow biopsy, bone scan and routine blood
investigations will be necessary 12.
Histopathology
Retinoblastoma appears as a basophilic mass with
lightly eosinophilic areas due to necrosis of tumor and/
or multiple dense basophilic foci (due to calcification)
within areas of necrosis may be seen. The tumor may
Fig. 4. MRI Scan in a child with unilateral retinoblastoma
September 2009 P. Mahesh Shanmugham : Retinoblastoma 245
GroupTumor characteristics
A Small tumor (≤ 3mm)
B � Larger tumor (≥ 3mm)
� ≤ 3 mm from foveola
� ≤ 1.5 mm from disc
� Subretinal fluid ≤ 3mm from margin
C Focal seeding
� Subretinal and or vitreous seeds
≤ 3 mm from tumor
D Diffuse seeding
� Subretinal and or vitreous seeds
≥ 3 mm from tumor
E � Tumor >50 % globe
� Neovascular glaucoma
� Opaque media due to intraocular hemorrhage
� Postlaminar optic nerve invasion, choroid
(>2 mm), sclera, orbit anterior chamber
involvement
Treatment of retinoblastoma 1, 15
Management of retinoblastoma confined to
the eye: Eyes with visual potential (unilateral/bilateral
cases) are managed conservatively. Primary or recurrent
tumours anterior to equator, ≤ 4 mm in diameter and
less than 3 mm thickness, confined to the retina are
treated with triple freeze thaw cryotherapy. Tumors
3-4 mm in diameter, 2 mm thick confined to the retina
are treated with 2 rows of deep laser burns around the
tumor. Slightly larger tumors confined to the retina can
be treated with transpupillary thermotherapy, which is
increasing the tumor temperature by 6-80 C above body
temperature.
Larger tumors or those with vitreous or subretinal seeds
are treated with external beam radiation delivering
3500-4000 cGy, 200 cGy fractions delivered over a
4-5 week period. Plaque brachytherapy with episcleral
plaque applicators (Iodine - 125 or Ruthenium - 106)
can be used to treat tumours ≤ 15 mm in diameter and
6-8 mm in height, at least 2 mm from optic disc and
fovea with or without localized vitreous seeding. Plaque
therapy has the advantage of limited radiation to
normal tissue, thereby limiting complications. Radiation
in any form is associated with complications such as
retinopathy, cataract and in bilateral germinal tumors,
the increased risk of second malignant neoplasms in
later years 16. The risk of second malignant neoplasms
is highest when the child subjected to radiation less
than 1 year of age. Hence it is preferable to avoid
radiation and CT scan in retinoblastoma infants less
than one year of age.
Contemporary management of large tumors, tumors
close to optic nerve (Fig 5) / fovea or those extending
beyond the retina involves using chemoreduction.
Triple drug chemoreduction using vincristine, etoposide
and carboplatin are used in multiple cycles to
“chemoreduce” the tumor and the residue is destroyed
using focal treatments such as laser photocoagulation,
cryotherapy etc., The tumor is replaced with
chorioretinal atrophy and calcific residue with
chemoreduction and local treatment. (Fig 6, 7) Current
focus is on local chemotherapy and one of the avenues
being explored in cannulation of the ophthalmic artery
and melphalan infusion through the same.
Fig. 5. Large tumor mass filling the globe
Fig. 6. Regressed retinoblastoma showing chalky whiteareas of calcification and chorioretinal atrophy
246 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Subconjunctival carboplatin chemotherapy is also used
as an adjunct to systemic chemotherapy.
This shift from radiation to chemoreduction is primarily
aimed at reducing the increased risk of second
malignant neoplasms associated with the use of
radiation.
Enucleation is indicated in retinoblastomas involving
more than half the globe, presence of glaucoma and
anterior chamber involvement. A long optic nerve
stump (≥10 mm in length) should be obtained during
enucleation. If post enucleation histopathological
tumor, excision of the tumor followed by additional
chemotherapy and radiation to the affected part.
Intracranial involvement is treated with intrathecal
chemotherapy in addition to CNS radiation and
systemic chemotherapy.
Prognosis
The overall 5-year survival is around 90 percent in
retinoblastoma. Patients with germinal mutations are
more likely to die due to second nonocular tumors,
which develop at a later age. Involvement of the cut
end of the optic nerve indicates poor prognosis and
possible intracranial metastatic disease if adequate (at
least 10 mm) length of the optic nerve stump was
obtained during enucleation. Tumor invasion into the
ocular coats, extensive choroidal invasion and anterior
chamber seeding are associated with an increased risk
of subsequent metastatic disease. Extraocular, central
nervous system involvement and hematogenous spread
carry a poor prognosis.
References
1. Shields JA, Shields CL. Retinoblastoma. Clinical and
pathologic features. In: Intraocular tumours: A Text andAtlas. WB Saunders, Philadelphia, 1992, pp 305-331.
2. Senft S, al-Kaff A, Bergqvist G, et al. Retinoblastoma.The Saudi Arabian experience. Ophthalmic PaediatrGenet 1988;9:115-119.
3. Kock E, Naeser P. Retinoblastoma in Sweden 1958-1971.
A clinical and histopathological study. Acta Ophthalmol1979:57:344-350.
4. Francke U. Retinoblastoma and chromosome 13.Cytogenet Cell Genet 1976;16:131-134.
5. Yunis JJ, Ramsay N. Retinoblastoma and subbanddeletion of chromosome 13. Am J Dis Child 1978; 132:
161-163.
6. Shanmugam MP, Biswas J, Gopal L, Sharma T,
Nizamuddin SH. The clinical spectrum and treatmentoutcome of retinoblastoma in Indian children. J Pediatr
examination shows tumor invasion beyond lamina
cribrosa, anterior segment involvement (Fig. 8) or extensive
choroidal invasion, adjunctive chemotherapy is necessary
to decrease risk of subsequent metastatic disease.
Involvement of the cut-end of optic nerve with tumor
has to be treated aggressively with adjunctive
chemotherapy and radiation.
Management of extraocular retinoblastoma:
(Fig 9 – showing orbital recurrence of retinoblastoma)
Extraocular retinoblastoma is managed with a multi-
modal approach of chemoreduction to reduce the
Fig. 7. Regressed retinoblastoma showing extensive chorioretinal atrophy and flecks of calcification
Fig. 8. Advanced tumor showing anterior segmentinvolvement
Fig. 9. Orbital recurrence of tumor following enucleation
September 2009 P. Mahesh Shanmugham : Retinoblastoma 247
Ophthalmol Strabismus. 2005 Mar-Apr;42(2):75-81;quiz 112-3.
7. Vemuganti G, Honavar S, John R. Clinicopathologicalprofile of retinoblastoma in Asian Indians. InvOphthalmol Vis Sci 2000;41(S790);4.
8. Sahu S, Banavali SD, Pai SK, et al. Retinoblastoma:problems and perspectives from India. Pediatr HematolOncol 1998;15:501-508 .
9. Rubenfeld M, Abramson DH, Ellsworth RM, et al.Unilateral vs. bilateral retinoblastoma. Correlationsbetween age at diagnosis and stage of ocular disease.Ophthalmology 1986;93:1016-1019.
10. Kayembe L. Retinoblastoma: 21-year review. J FrOphthalmol 1986;9:561-565.
11. Mathew L, Miale TD, Rao S, et al. Retrospective analysisof 58 children with retinoblastoma. Ophthalmic PaediatrGenet 1984; 4:67-74.
12. Mohney BG, Robertson DM. Ancillary testing for
metastasis in patients with newly diagnosed
retinoblastoma. Am J Ophthalmol 1994;118:707-711.
13. Epstein J, Shields CL, Shields JA. Trends in the
management of retinoblastoma: evaluation of 1,196
consecutive eyes during 1974–2001. J Pediatr
Ophthalmol Strabismus. 2003;40:196–203.
14. Shields CL, Shields JA. Basic understanding of current
classification and management of Retinoblastoma. Curr
Opin Ophtalmol 2006;17:228–234.
15. Shields CL, Mashayekhi A, Demirci H, et al. Practical
approach to management of retinoblastoma. Arch
Ophthalmol. 2004;122:729-735.
16. Abramson DH. Retinoblastoma in the 20th Century: Past
Success and Future Challenges The Weisenfeld Lecture.
Inv Ophthalmol Vis Sci. 2005;46:2684-2691
248 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Ocular Manifestations of Intracranial Space
Occupying Lesions – A Clinical StudyDr. K.V. Raju MS, Dr. Anju Abdul Khader MS
nuclei are associated with the eyes besides the vagus
and the sympathetic. This research work covers the
assessment of the incidence of ophthalmologic
manifestations in intracranial space occupying lesions,
and to correlate the ocular manifestations and the site
of the brain tumours as well as the study of the visual
field defects caused by space occupying lesions.
Aim of the Study
To study the incidence of ophthalmologic
Abstract
Aim
� To study the various ophthalmologic manifestations in intracranial space occupying lesions.
� To correlate the ocular manifestations and the site of the brain tumors.
� To study the visual field defects caused by space occupying lesions.
Materials and methods
The study included fifty CT/MRI proven cases of intracranial space occupying lesions who underwent
detailed ocular, neurological and systemic examination.
Results
Female patients in the 40-50 yrs age group were commonly affected. Headache was the common
symptom [63.3 %] followed by defective vision.VII Cranial nerve was most commonly involved.
Papilloedema was the most common fundus finding. Visual field defects correlated with the
site of tumour. Most common histological subtype was neuroepithelial tumours.
Cerebellopontine angle tumours were most common according to the site of tumour.
Keywords. Ocular manifestations, intracranial space occupying lesions, visual field defects.
Introduction
Ocular features sometimes form an early manifestation
of intracranial space occupying lesion, which helps us
to diagnose the condition earlier and decrease the
morbidity and mortality of the patient. How far the
ophthalmologist’s effort can be useful to the neurologist
can be judged from the extensive distance the optic
pathways cover in the brain from pole to pole, and from
the fact that six of the twelve cranial nerves with their
Regional Institute of Ophthalmology, Calicut Medical College
ORIGINAL
ARTICLE
September 2009 Raju K.V. et al. - Ocular Manifestations of ICSOL 249
manifestations in intracranial space occupying lesions,
to correlate the ocular manifestations and the site of
the brain tumours and also to study the visual field
defects caused by space occupying lesions.
Methods
The materials for the study were collected from the
patients who attended Regional Institute of
Ophthalmology, Calicut Medical College, during one
year period [May 2005 - May 2007]. Most of the
patients were admitted in the Neurosurgery Department
and the ophthalmologic evaluation was done in the
preoperative period. Patients with CT or MRI proved
intracranial space occupying lesions were taken up for
the study. Those patients who were uncooperative on
account of very young age, deteriorating general
conditions or marked behavioural disorders were
excluded from the study.
Fifty patients with brain tumours and eye
manifestations were included in the study. In each case
clinical evaluation was done after obtaining a detailed
history. Ophthalmologic assessment included
routine ocular examination with special reference to
ocular movements, corneal sensation, pupillary
abnormalities and nystagmus. Ocular fundus was
examined in detail and visual fields charted in all cases.
A complete examination of the central nervous system
which included examination of the higher functions,
cranial nerves, motor system, sensory system and
cerebellar signs were made.
Observation and Discussion
1) Age distribution [Table :1]
The age of patients ranged from 11- 65 years. The
maximum incidence in the present study was in the
age group between 40 to 50.1 This is in accordance
with other studies by Rao et al, which showed a 52 %
incidence in the 3rd & 4th decade.
2) Sex distribution:
The present study showed a female preponderance
of 60 %.
3) Area of involvement of brain tumors and
histopathological types of brain tumors.
[Table :2]
In the present study according to the site of tumor most
common was cerebellopontine angle tumors [20 %].
According to the histology the most common tumor
found in our study was neuroepithelial tumors [34 %]
like astrocytoma, oligodendroglioma, ependymoma etc.
4) Presenting symptoms:.
In this series maximum no of patients presented with
headache. Headache as initial symptom occurred in
30 % and along with other symptoms occurred in
63.3 %. S.Sood et al also made similar observation.
Defective vision occurred during the course of the
disease in 50 % of the patients. Seizures either
generalized or focal occurred in 3.3 %. Behavioural and
psychiatric changes were noted in patients with parietal,
frontal & temporal lobe tumors. Other symptoms
included vertigo, paresis, dysphasia, dementia,
deafness, tinnitus ataxia, and diplopia etc.
5) Pupillary abnormalities
Among the 50 patients examined 6[12 %] had
abnormal pupillary reaction. All of them had afferent
pupillary defect due to optic atrophy. Although
Wernicke pupil has no significance according to the
literature one patient in this study with left parietal
meningioma and homonymous hemianopia showed the
defect.
6) Papilloedema
Uhthoffs [1914] study of bilateral papilloedema showed
the etiology in 71 % as brain tumors, 12 % cerebral
syphilis, 3.6 % cerebral oxycephaly, brain abscess and
meningitis 2.2 % each. In this study 56 % of the patients
had papilloedema during presentation. Posterior fossa
tumors presented with papilledema earlier where as
cortical & pituitary tumors presented late. Optic nerve
fibres are compressed by elevated cerebrospinal fluid
pressure in the subarachnoid space of the intraorbital
portion of the optic nerve. Subsequent swelling of axons
and leakage of water, protein, and other axoplasmic
Table 1: Age distribution.
Age group Percentage
<10 6 %
10 to 20 6 %
20 to 30 22 %
30 to 40 20 %
40 to 50 30 %
>50 16 %
250 Kerala Journal of Ophthalmology Vol. XXI, No. 3
contents into the extra cellular space causes venous
obstructions, nerve fibre hypoxia and vascular
telangiectasis of the disc as secondary events.
Therefore, papilledema is primarily mechanical rather
than a vascular phenomenon. Normally the disc edema
takes 1-4 days to develop after the increase of CSF
pressure.
7) Cranial nerves [Table:3]
Expanding supratentorial mass lesions displaces cerebral
tissues to compress the brainstem structures. During
this process the nerves innervating the extraocular
muscles are stretched resulting in false localizing sign.
VI nerve may be stretched over the petrous tip between
its point of emergence from the brainstem and its dural
attachment to the clivus. This is due to the downward
descent of the brainstem and may occur with posterior
Table 2 : Area of Involvement & Histopathological subtypes
Area of lesion Histopathology Percentage
Parietal lobe Meningioma-2
Malignant Ependymoma-1 14 %
Glioblastoma multiforme-1 Astrocytoma-2
Epidermoid cyst-1
Fronto parietal Astrocytoma-1 6 %
Meningioma-2
Frontal Meningioma-3
Glioblastoma multiforme-2 12 %
Abscess-1
Fronto temporal Astrocytoma-1
Oligodendroglioma-1 6 %
Glioblastoma multiforme-1
Temporal Pilocytic astrocytoma-1 4 %
Caver. Haemangioma-1
CP angle tumour Acoustic neuroma-7 20 %
Meningioma-1
Glioma-2
Parieto occipital
Astrocytoma-1
Glioma-1 6 %
Abscess-1
Perichiasmatic Pituitary tumours-3
Craniopharyngioma-5 18 %
Tuberculum Sellae Meningioma-1
Cerebellum Medulloblastoma-1 4 %
Glioma-1
Ventricle Colloid cyst-3 8 %
Epidermoid-1
Corpus callosum Glioma-1 2 %
Table 3: Distribution of cranial nerve palsy
Cranial Nerve Palsy Percentage
IIIrd nerve 3.12
VI nerve 21.86
VII nerve 31.2
VIII nerve 18.74
IX, X nerves 6.25
V nerve 18.74
September 2009 Raju K.V. et al. - Ocular Manifestations of ICSOL 251
fossa tumours. Bilateral palsy of VI nerve may be a false
localizing sign. Cranial nerves were involved in 64 %.
Cerebellopontine angle tumors were associated with
cranial nerve involvement [5, 7, 8 cranial nerves
involved in 100 % & 9, 10 cranial nerves involved in
6.25 %]
8) Hemiparesis
Pyramidal tract involvement with some form of hemi
paresis was seen in seven patients.
9) Cerebellar signs
All cases of cerebellopontine angle tumors were
associated with cerebellar signs.
10) Optic atrophy [Table:4]
Optic atrophy was seen in 9 patients. 3 patients had
primary optic atrophy [all cases were
craniopharyngiomas]. Post-neuritic optic atrophy
following papilledema was seen in rest of the cases.
accounts for the characteristic visual field defect. It was
seen in 2 cases of craniopharyngioma and one
tuberculum sellae meningioma. (c) Homonymous
hemianopia occurs in optic tract lesions due to tumors
in temporal, frontal, parietal & occipital lobes. It was
seen in 6 cases -2 parietal lobe lesions, 2 frontoparietal
& 2 temporal lobe lesions. (d) Homonymous superior
quadrantanopia was seen in one case of temperofrontal
meningioma due to involvement of the inferior fibres
in the optic radiation. (e) Homonymous inferior
quadrantanopia was seen in one case of parietal tumour
due to involvement of superior fibres in the optic
radiation passing through the parietal lobe.
Frontal lobe tumors
Patients with frontal lobe tumors showed behavioral
abnormalities, dementia, seizures & urinary
incontinence. Three out of the nine had convulsions.
Gliomas were the most common tumors of the frontal
lobe. 9 % of the frontal lobe tumors showed
homonymous hemianopia and 50 % showed peripheral
constriction of visual fields.
Temporal lobe lesions
Temporal lobe involvement was seen in 6 out of the
50 patients. 20 % of the cases showed superior
quadrantanopia & 25 % showed homonymous
hemianopia.
Cerebellopontine angle tumours
There were 10 cases with CP angle tumours. All of them
had deafness, ataxia, impaired corneal sensation,
papilledema and 7th and 8th nerve palsies. Other features
Table 4: Percentage of optic atrophy.
Optic Atrophy Percentage
Primary optic atrophy 2
Secondary optic atrophy 12
Total 18
Table 5: Distribution of visual field defects
Field defect Percentage Cases
Bitemporal hemianopia 7.14 Craniopharyngioma, tuberculus sellae meringroma
Homonymous hemianopia 21.43 Parietal astrocytoma, Parietal epidermoidFronto parietal meningioma Tem parietal oligodendroglioma Tem.pilocystic astrocytoma
Homo.superior quadrantanopia 3.57 Fronto temp.meningiomaHaemangioblastoma cerebellum
Homo.inferior quadrantanopia 3.57 Glioblastoma multiforme
Parietal lobe
Blind spot enlargement 53.57
Peripheral constriction 28.57
11) Visual field defects [Table:5]
Visual field testing helps in localizing and lateralizing
the intracranial lesions. Most field defects of
neurophthalmic significance are located in the central
30-degree field. 56 % of the patients in this study
showed field defects. (a) Blind spot enlargement was
the most common. (b) Bitemporal hemianopia - The
partial decussation of nerve fibres in the optic chiasm
252 Kerala Journal of Ophthalmology Vol. XXI, No. 3
include gaze induced nystagmus, brun’s nystagmus,
tinnitus and dysphasia. In the present study the
incidence of raised ICT as evidenced by papilledema
was seen in 80 % of cases. Papilledema occurred
secondary to hydrocephalus as a result of aqueductal
obstruction by the tumour. Papilledema may sometimes
result due to increased protein secretion by the tumour.
Optic atrophy is secondary to papilledema. In the
present study nystagmus is seen in 20 % of cases of CP
angle tumours.
Conclusion
Ocular manifestations occur very frequently in
ICSOL,which in some cases helps us to diagnose the
condition. Headache was the most common symptom
followed by defective vision. Cranial nerve involvement
was seen in many cases, most common of which was
sixth nerve palsy. Papilledema was the most common
fundus finding followed by optic atrophy. Visual field
abnormality was seen in majority of cases out of which
blindspot enlargement was most common followed by
bitemporal hemianopia, homonymous hemianopia,
superior and inferior quadrantanopia. Distribution of
brain tumours showed CP angle tumours to be most
common followed by parietal lobe, frontoparietal,
frontal, frontotemporal, temporal and parieto-occipital
lobe. This study emphasizes the importance of ocular
manifestations in the localization, extent of the lesion,
prognosis for vision and life of the patient, in the case
of brain tumours.
References
1. Rao KV, Subramanyam M, Rao BS. Papilledema. IndianJournal of Ophthalmology 1982; 30: 465-7.
2. Sood NK, Sharma M, Nada A, Dutt RC, Nagpal.Correlation between CT Scan and Automated Perimetryon Supratentorial Tumours. Neurology India. June2002, 50; 2: 158-161.
3. Duanes Clinical Ophthalmology, Vol.2, 1996. WillaimTasman, Edward A, Jaeger.
4. Duke-Elder, Sytem of Ophthalmology, Vol.XII,Neuroophthalmology, 1967.
5. Hayreh SS. Pathogenesis of Edema of Optic Disc. BJO,48: 522-543, 1964.
6. Huber A, Eye Signs and Symptoms in brain tumours.Blodi FC. 3rd Edition, St.Louis, C.V.Mosby, 1976.
7. Smith JL. Homonymous Hemianopia: A review of 21patients. Arch. Ophthalmol. 96; 656-663; 1978.
8. Miller NR. Walsh and Hoyt ClinicalNeuroophthalmology 3rd Edition, Vol.I&III. 1984.
9. Chamlin M et al. Ophthalmologic Changes Producedby Pituitary Tumours. Am. J. Ophthalmology 40: 353;1955.
10. Adler’s Text Book of Physiology.
September 2009 Raju K.V. et al. - Ocular Manifestations of ICSOL 253
Capsulo-Cortical Adhesions (CCA) and
Phacoemulsification (PE)Dr. Arup Chakrabarti MS, Dr. Sonia R John DNB, Dr. Valsa T Stephen MS DNB,
Dr. Meena Chakrabarti MS DNB
One of the basic requirements of modern techniques
of phacoemulsification is free rotation of the
nucleus 1, 2, 3. A freely mobile nucleus 4 is a sign that it is
totally separated from the capsular bag and subsequent
maneuvers of the nucleus are likely to place minimal
stress on the zonules. Rotation is achieved by cortical
cleaving hydrodissection 5 which separates the nucleus
from the capsular bag.
Sometimes it may be difficult or impossible to rotate
the nucleus despite meticulous cortical cleaving
hydrodissection. If faulty technique of cortical cleaving
hydrodissection has been ruled out, it is usually the
presence of capsulo-cortical adhesions that makes
nucleus rotation difficult.
Capsulo-cortical adhesions are characterized by
adhesions between the capsule and cortex (Figures 1a
and 1b). These adhesions may be anterior, posterior,
equatorial or any combinations of the above. Unlike in
a cortical cataract, there is no definite area of
translucence visible between the capsule and the
underlying opaque cortical layers in capsulo-cortical
adhesions. Opacity exists in the outermost layers of the
cortex that is adherent to the lens capsule. These
adhesions can be assessed at the slitlamp as well as the
operating microscope, to a certain extent.
This prospective study was conducted to look into the
peculiarities and difficulties faced by the surgeon while
operating on cataracts with capsulo-cortical adhesions.
The goal was to prepare a guideline for safe
management of these cases.
Patients and Methods
86 consecutive patients with capsulo-cortical adhesions
scheduled for phacoemulsification (Group A) were
included in this prospective study. The diagnosis of
capsulo-cortical adhesion was made intraoperatively
just before starting the surgery with the patient under
the operating microscope after prepping and draping
of the patient. The intraoperative findings were
matched with the slitlamp examination findings
documented in the casesheet during preoperative
evaluation. All these patients had been preoperatively
assessed at the slitlamp with a fully dilated pupil.
Exclusion criteria included patients with prior ocular
surgery, ocular disease, complicated cataract and
nondilating pupils. 20 consecutive patients with
routine uncomplicated cataract, scheduled for
phacoemulsification were also included in the study
as controls (Group B). The exclusion criteria,
Fig. 1a. Capsulo-cort icalAdhesion on diffuseillumination
Fig. 1b. Capsulo-corticalAdhesions on
retroillumination
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
ORIGINAL
ARTICLE
254 Kerala Journal of Ophthalmology Vol. XXI, No. 3
surgical technique and protocols were the same in each
group.
Phacoemulsification was performed by a single surgeon
(AC). All surgeries were performed under topical
anesthesia with 2 % xylocaine jelly through the
temporal clear corneal approach. The anterior capsule
was stained with trypan blue dye (0.06 %) under an
air bubble. Continuous curvilinear capsulorhexis was
performed under 2 % hydroxypropyl methyl cellulose
using a 26 gauge bent needle. A three-site cortical
cleaving hydrodissection (3,9 and 6 o’clock) was
performed by injecting BSS through a 26-gauge cannula
attached to a 2 ml syringe. The cannula tip was
advanced under the anterior capsule approximately till
the capsular fornix, the anterior capsule tented and BSS
was gently injected until a complete fluid wave was
observed between the lens and the posterior capsule.
The shallowing of the anterior chamber was also
considered as one of the endpoints of cortical cleaving
hydrodissection. The capsular bag was decompressed
by gently tapping on the anterior lens capsule with the
hydrodissection cannula itself. The anterior chamber
was refilled with viscoelastic and nucleus rotation was
attempted with a Sinskey hook through the side port.
If the nucleus did not rotate freely, no effort was made
to attempt a forcible rotation. Additional multiquadrant
hydrodissection was performed in two more sites that
also included the area of capsulo-cortical adhesion. The
cannula was also passed subcapsularly in an attempt
to lyse the anterior capsulo-cortical adhesions by
employing the concept of hydrofree dissection. Nucleus
rotation was attempted again and the surgeon noted
down the subjective difficulty encountered during
nucleus rotation. If the nucleus did not rotate, another
round of cortical cleaving hydrodissection was repeated
once again at two different points. Subsequently,
phacoemulsification was performed. A phacochop or
stop and chop phacotechnique was employed using the
Bausch and Lomb Millennium phaco unit. The surgeon
looked out for any peculiarity or uniqueness in these
cases. All cases were recorded in a DVD. Subsequently
each of the recorded cases was analysed for a) the total
duration of the actual surgical procedure, b) the total
time required to perform rhexis and c) the total time
required for cortical cleaving hydrodissection.
Results
86 patients were noted to have capsulo-cortical
adhesions at the start of the surgery. The average age
Different types of CCAs seen on diffuse illumination (a),retro illumination (b) and slit beam illumination (c)
Table 1: Patient Profile
Group A Group B(N = 86) ( N = 20)
Age (Years)
Upper limit 87 82
Lower limit 46 32
Mean 67 61.7
Sex
Male 43 11
Female 43 09
Associated systemic disease
Nil 19 (22.09 %) 53 (61.63 %)
Diabetes Mellitus 5 (25 %) 10 (50 %)
September 2009 Arup Chakrabarti et al. - CCA and PE 255
of the patients was 67.1 years (range 46 years to
87 years). The sex distribution was even with
43 patients in each category (Table 1).
19 patients had no systemic illnesses with diabetes
mellitus being the commonest systemic association
resistance was always encountered while performing
the rhexis in the area of the capsulo-cortical adhesion.
Nucleus rotation could be performed after the first
sequence of cortical cleaving hydrodissection in
83 cases. However in 5 of these cases (5.81 %) the
rotation was difficult and stressful though no untoward
damage like zonular dialysis was noted. It could be
completed only after the second sequence of cortical
cleaving hydrodissection. In 3 cases (3.49 %) the
nucleus could not be rotated. Milky turbid fluid
(Figure 2) was noticed to originate from the area of
the capsulo-cortical adhesions in 10 patients (11.63 %)
at the stage of nucleus decompression during cortical
cleaving hydrodissection. There were no significant
intraoperative complications like posterior capsular rent
or zonular dialysis in any of these patients. Visual
recovery of 6/9 or better on the 5th postoperative day
was seen in 76 patients (88.37 %).
Discussion
Free and easy nucleus rotation is an important
prerequisite in all the modern techniques of
phacoemulsification.It considerably reduces the stress
placed on the zonules and capsular bag during removal
of the nucleus or nuclear fragments. Cortical cleaving
hydrodissection is a step, which is aimed to completely
separate the nucleus from its adhesions rendering it
freely mobile within the capsular bag. This separation
may be difficult or stressful and is at times impossible
in the presence of capsulo-cortical adhesions (CCA).
It is therefore important to be able to detect the
presence of capsulo-cortical adhesions before the
cortical cleaving hydrodissection step. A meticulous
dilated slitlamp evaluation preoperatively helps to a
great extent in diagnosing the presence of this
condition. One should also look for this condition with
the patient in extreme gaze. However one may miss
the diagnosis of capsulo-cortical adhesion in the
presence of a nondilating pupil or a dense cataract.
Even if the condition is missed during the preoperative
evaluation (for cataract surgery) a surgeon aware of
this entity should be in a positon to make a diagnosis
of capsulo-cortical adhesion intraoperatively. There
were 13 cases (15.12 %) of capsulo-cortical adhesions
which were undetected preoperatively and detected
intraoperatively in the current study.
Type of Cataract Group A Group B(No .86) (No. 20)
1. Anterior Subcapsular +Posterior Subcapsular 12 (13.95 %) 3 (15 %)
2. Anterior Subcapsular +Nuclear 4 (4.65 %) 2 (10 %)
3. Anterior Subcapsular +Posterior Subcapsular + White 6 (6.98 %) -
4. Anterior Subcapsular +
Posterior Subcapsular+Nuclear 64(74.41 %)15 (75 %)
(61.63 %) in those with concurrent systemic illness.
The type of cataracts associated with capsulo-cortical
adhesion are given in Table 2.
The mean total duration of the surgical procedure as
defined by the time from first incision till the application
of the eye pad at the conclusion of surgery was 22.68
minutes (range: 47.16 minutes to 14.23 minutes). The
mean duration of time when the surgical steps were
actually performed was 14.91 minutes (range: 36.14
minutes to 9.11 minutes). The mean time taken for
rhexis was 1.39 minutes (range: 4.51 minutes to
0.46 seconds). The mean time taken for cortical
cleaving hydrodissection was 2.13 minutes
(3.35 minutes to 0.13 seconds) (Table 3).
Group A Group B(N = 86) (N = 20)
Elapsed Phaco Time (min) 1.16 1.03(5.1 to 0.52) (2.48 to 0.34)
Absolute Phaco Time (min) 0.16 0.10(1.3 to 0.01) (0.24 to 0.03)
Average Phaco Power (%) 21.46 22
(70 to 40) (27 to 5)
The capsulo-cortical adhesions encroaching into the
pupillary area tended to render the red fundal glow
(whenever present) a bit dull as opposed to rest of the
central areas with a brighter red reflex. Trypan blue
staining of the anterior capsule enhanced the visibility
of the capsular tear at the zone of the adhesions. Some
256 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Cortical cleaving hydrodissection should be performed
meticulously. The cannula tip should tent the anterior
capsule and the fluid injection should be performed
close to the capsular fornix. Mechanical lysis of the
adhesion with the same cannula or a cyclodialysis
spatula may be attempted. Signs of successful
hydrodissection include a fluid wave across the
posterior capsule, shallowing of the anterior chamber
due to forward bulging of the nucleus, a prominent
capsulorhexis edge and release of trapped fluid from
the rhexis margin when the nucleus is tapped back.
We routinely perform 3 - quadrant cortical cleaving
hydrodissection even in our standard cases before
attempting nucleus rotation. The same strategy was
adopted in the study too, and this is more likely to lyse
the adhesions than a one-point hydrodissection. This
explains the high success rate of nucleus rotation in
our study after the first sequence of cortical cleaving
hydrodissection. No additional force is to be used to
rotate the nucleus in the event of any difficulty and a
repeat 3 quadrant cortical cleaving hydrodissection is
called for.
Sometimes, inspite of a good cortical cleaving
hydrodissection, where the posterior fluid wave has
been visualized and focal lysis of the capsulo-cortical
adhesions has been performed, it may be difficult to
rotate the nucleus. It could be due to the presence of
equatorial adhesions and further multiquadrant
hydrodissection should be done before attempting to
rotate the nucleus.
The milky fluid (Figure 2) seen to emanate from the
area of capsulo-cortical adhesions (in 10 patients,
11.63 %) while decompressing the capsular bag at that
area seem interesting. The furry epinuclear surface
(Figure 3) present focally at the area of the adhesions
were noted in many cases and could be a result of lysis
of the fibrous adhesions between the anterior capsule
and underlying cortex.
Time required to perform rhexis as well as cortical
cleaving hydrodissection was more in the patients with
capsulo-cortical adhesions when compared to the
control group.
In conclusion, a thorough preoperative dilated slitlamp
evaluation should be performed to detect capsulo-
cortical adhesions. Intraoperative evaluation also helps
to detect some cases of capsulo-cortical adhesions not
detected by prior slitlamp examination. Before any
attempt at nucleus rotation a 3-point cortical cleaving
hydrodissection as well as focal and hydrofree
dissection are strongly recommended.
Reccomendations
• Detection of Capsulo cortical adhesions is
important before hydrodissection
• Meticulous dilated slitlamp evaluation
preoperatively is mandatory
• Capsulo cortical adhesions may be missed in non
dilating pupil or dense cataract
• Can be diagnosed intraoperatively even if missed
initially
• Meticulous cortical cleaving hydrodissection in
presence of Capsulo cortical adhesions
– Fluid injection after tenting of anterior capsule,
close to capsular fornix
– Mechanical lysis with cannula or cyclodialysis
spatula
• Signs of successful hydrodissection
– Fluid wave across the posterior capsule
– Shallowing of anterior chamber
– Prominent capsulorhexis edge
– Release of trapped fluid from the rhexis margin
when nucleus is tapped back.
• In presence of equatorial adhesions, further
multiquadrant hydrodissection to be done before
attempting nucleus rotation.
• Milky fluid emanating from area of adhesions-
could be result of lysis of adhesions
Fig. 3. Furry epinuclearsurface indicating thepresence of capsulo-cortical adhesions
Fig. 2. Milky turbid fluidfrom the area of
c a p s u l o - c o r t i c a ladhesions.
September 2009 Arup Chakrabarti et al. - CCA and PE 257
Guidelines in Patients with Capsulo
cortical adhesions
CCA is a frequent phenomenon and often underdiagnosed
• Establish diagnosis preoperatively. (caution to be
exercised in total cataract/small pupils)
• TB staining of the anterior capsule
• Meticulous cortical cleaving hydrodissection.
• Hydrofreedissection may be beneficial
• No forcible nucleus rotation
• Capsular tension ring/Injector to be kept handy
Conclusion
• Thorough preoperative dilated slitlamp evaluation
mandatory
• Intraoperative evaluation to detect missed cases.
• Increased suspicion when lens milk visualized in
preoperatively undiagnosed cases.
• A 3 point cortical cleaving hydrodissection and
hydrofree dissection to be performed before
attempting nucleus rotation.
References
1. Gimbel HV. Divide and conquer nucleofractis
phacoemulsification: development and variations. J
Cataract Refract Surg 1991; 17:281-291
2. Shepherd JR. In situ fracture. J Cataract Refract Surg
1990; 16:436-440.
3. Vasavada AR, Singh R. Step-by-step chop in situ and
separation of very dense cataracts. J Cataract Refract
Surg 1998; 24:156-159.
4. Gimbel HV. Hydrodissection and hydrodelineation. Int
Ophthalmol Clin 1994;34(2):73-90.
5. Fine IH. Cortical cleaving hydrodissection. J Cataract
Refract Surg 1992; 18:508-512.
258 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Efficacy of Combining Intravitreal
Bevacizumab Monotherapy (IVB) with
Panretinal Photocoagulation(PRP) In Early
Stages of Neovascular Glaucoma (NVG)Dr. Meena Chakrabarti MS DO DNB, Dr. Arup Chakrabarti MS, Dr. Sonia Rani John DNB
Anterior Segment neovascularisation results from
several ocular and systemic diseases that predispose
patients to retinal hypoxia and ischemia with
subsequent release of angiogenesis factors such as
vascular endothelial growth factor. Bevacizumab
(Avastin), a recombinant antibody against vascular
endothelial growth factor (VEGF), has been shown
to effectively reduce neovascular activity and
vascular permeability in ocular tissues. Administration
of intravitreal Bevacizumab in the early stages of
neovascular glaucoma (characterized by
presence of neovascularisation of iris and
angle, elevated IOP by the open angle
mechanism) may dampen the neovascular trigger.
When combined with panretinal photocoagulation
(on the same day) control of the ischemic process is
ensured and further progression to advanced secondary
angle closure neovascular glaucoma may be prevented.
Clinical Objective: To study the efficacy of
combining intravitreal Bevacizumab (Avastin)
injection with same day panretinal photocoagulation
in eyes with early neovascular glaucoma (Stage II,
Open angle mechanism prior to development
of peripheral anterior synechiae and angle
closure)
Primary Outcome Measures: Regression of
neovascularisation of iris, and neovascularisation of the
angle were the primary outcome measures that we
studied.
Brief Review of Pertinent Literature:
1. Oshima et al1 reported a series of seven eyes with
neovascularisation of iris (NVI) secondary to
proliferative diabetic retinopathy. The NVI
regressed in all patients at one week and repeated
injections stabilized the recurrence in 2 eyes that
was seen 2 months after the initial injection. IOP
was controlled in 6 eyes throughout the follow
up period with no inflammation and
complications.
2. Tripathi et al2 have shown that patients with NVG
had significantly increased levels of VEGF in the
aqueous humor. They discussed the possible role
of ciliary epithelium, in addition to the retina, in
the production of VEGF and the complementary
functions of basic fibroblast growth factor and
other growth factors.
3. Davidorf et al3 described the regression of
NVI and NVA in a patient with choroidal
melanoma and diabetes (treated with TTT and
PRP), following intravitreal injection of
Bevacizumab.Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
ORIGINAL
ARTICLE
September 2009 Meena Chakrabarti et al. - Combination therapy in NVG 259
4. Mason et al4 proposed the use of IVB for patients
with NVG, recurrent hemorrhage from NVI and
for those who despite PRP develop NVI. Tube
drainage procedures may be avoided by giving
intravitreal Bevacizumab injection as it causes
regression of iris and angle neovasularisation and
better IOP control medically.
5. Iliev et al5 described six consecutive NVG patients
with refractory symptomatic elevation of IOP who
received intravitreal Bevacizumab injection.
A marked regression of NVI, substantial IOP
reduction in 3 eyes, and symptomatic relief in all
eyes were observed in 48 hrs.
6. Grisanti et al6 described the regression of NVI in
6 eyes with PDR and NVG following intracameral
injection of Bevacizumab. As early as Day 1
decrease in leakage form the iris vessels was
observed by iris fluorescein angiography. No
inflammation or relapse was observed at 4 weeks.
7. Avery et al7 demonstrated the regression of retinal
and iris neovascualrisation due to PDR, following
the administration of IVB.
8. Vatavuk et al8 reported regression of iris and angle
neovacularisation with reduction of IOP in an eye
with NVG following CRAO.
9. Luis Amselemab9 et al have demonstrated the
efficacy of using Intravitreal Bevacizumab in
patients with ocular ischemic syndrome and
neovascular glaucoma. Although there was
regression of NVI and no recurrence on follow
up, no substantial IOP lowering effect or change
in vision could be demonstrated.
10. Ehlers et al evaluated the efficacy of combining
intravitreal Bevacizumab and panretinal
photocoagulation in the treatment of neovascular
glaucoma. Their results effectively showed that
combination therapy resulted in more rapid
decrease of IOP,increased frequency and rapidity
of regression of neovascularisation.
We conducted a prospective interventional study in
38 eyes with early stage II neovascular glaucoma that
underwent one of the three modes of intervention.
1) Isolated PRP (15 eyes); (2) IVB
Monotherapy (12 eyes) and combined
IVB and PRP ( 11 eyes)
a. Inclusion Criteria:
i. Presence of peripupillary neovascularisation of iris
and early neovascularisation of angle
ii. Elevated Intraocular Pressure
iii. Good fundus view
iv. H/o Laser Photocoagulation (for PDR:
Proliferative Diabetic Retinopathy/: Ischemic
Central Retinal Vein Occlusion) more than 3
months prior to enrolment.
v. Adequately controlled systemic co.morbid
conditions.
The randomization for enrolment into the various
treatment groups was biased in that high risk patients
with a history of prior thromboembolic episodes, or
coronary artery disease were advised to enroll in the
PRP group (Fig. 1). Likewise patients with higher
baseline IOP were enrolled into the combination group.
b. 38 eyes were studied and in bilateral cases
(3 patients) one eye received panretinal
photocoagulation and other eye received a
combination of intravitreal Bevacizumab and
panretinal photocoagulation.
c. Patients were age and gender matched as both
groups had patients with ages ranging from
48-75 years.
d. There was no control group and all patients
underwent one of the three methods of
intervention.
e. Methods of collecting patients: Patients attending
our out-patient department who satisfied our
inclusion criteria were included in this study.
Exclusion Criteria:
1. Florid NVI and presence of Peripheral anterior
synechiae (PAS.)
2. Advanced NVG
3. Corneal Changes, Hyphema, Cataract with
poor fundus view
260 Kerala Journal of Ophthalmology Vol. XXI, No. 3
3. Combined IVB + PRP group: included new
cases with no prior laser who presented with early
NVG and untreated retinopathy. PRP I was given
on the same day as the intravitreal injection and
the second sitting was given on the next day.
Recurrence in this group were treated by repeat
IVB injection (Fig. 2)
We evaluated the patient for any systemic adverse
effects especially thromboembolic episodes or acute
coronary events. Local side effects evaluated were:
vitreous hemorrhage, retinal detachment,
endophthalmitis and recalcitrant glaucoma.
The systemic adverse effects were evaluated by a
detailed history and by consultation with the treating
internist. Ocular side effects were assessed by post
treatment ophthalmic examination and follow up.
Outcome assessments: Outcomes were assessed in
all patients by (VS) and (SRJ). At each follow up
visit the following evaluations were performed.
1. Best corrected visual acuity
2. Non Contact Tonometry (Pulsair, Keeler)
3. Slit lamp examination of the anterior
segment.
4. Gonioscopy
5. Indirect Ophthalmoscopy
The parameters assessed were regression of NVI, by
slit lamp biomicroscopy and gonioscopy for regression
of NVA. The IOP was measured at each follow up visit
and a dilated fundus examination was performed.
All the patients were followed up at weekly intervals
for a period of 12 weeks ,at monthly intervals for 6
months, and 4 monthly for 1 year. All 38 patients
adhered to the follow up schedule.
The primary treatment outcome that we assessed was
for the regression of NVI Table:1 compares the effect
of intervention on the primary outcome ie time to
regression of NVI under the three different interventions
In the PRP group the mean time to regression of NVI
was 107.4+/- 19.3 in the PRP group, 51.5 +/-sd 14.5
days in the IVB Group, and 14.1+/-4.7days in the
combination group.Comparison of the time to NVI
regression under the three different interventions was
least in the combined group and was statistically
Therapeutic Intervention
1. PRP alone (15 eyes): underwent either primary
PRP in 2 sittings if they were unlasered or fill in
additional PRP if they had already undergone laser
photocoagulation previously. They were followed
up at weekly intervals and at each visit the best
corrected visual acuity, slit lamp examination,
applanation tonometry, gonioscopy and fundus
examination were performed. The regression of
NVI and the time to regression, presence or
absence of recurrence were carefully noted.
Repeat treatment for recurrence was by additional
PRP or by combining PRP with IVB.
2. IVB monotherapy (12 eyes) who had
undergone prior laser photocoagulation were
included in this group. Recurrences were treated
by fill in PRP or repeat IVB.
Fig. 1. Bar diagram showing distribution of cases in each groupbased on associated co-morbid condition
Fig. 2. Showing regression of NVE, NVI and decreased leakagein fluorescein angiography in a patient with NVGfollowing Ischemic Central Retinal Vein Occlusion
September 2009 Meena Chakrabarti et al. - Combination therapy in NVG 261
significant .(p=o.ooo ) using the Scheffe multiple
comparisons test.
Effect of intervention on the secondary outcome ie
control of intraocular pressure is given in Table : 2a-c.
The effect of intervention in controlling IOP was seen
in all the 3 groups at 2 weeks and sustained at 12 weeks.
However a further IOP lowering effect was seen at 12
weeks (p=0.002) in the combination group which was
statistically significant using the paired “ t” test.
Discussion
1) Effect of intervention in causing regression of NVI
and reducing the time to regression was most
significant in the group which received combined
PRP and IVB ( p = 0.000)
2) Effect of intervention in controlling the intraocular
pressure was maximum in the group which
received combined PRP and IVB at both 2 wks
and 12 weeks post intervention ( p=0.000 &
p= 0.002)
3) Recurrence occurred in 53.3 % of patients who
received PRP alone and 20% in the combined
group.
4) There was also a reduced need for repeat injection
in the combination group when comparing the
group that received IVB monotherapy versus
combination group (3.5 injection Vs 1.8 injection)
b) Limitation or Inherent Bias in the study design
1) The randomization for enrollment into the
various study groups was biased with respect
to co- morbid conditions. High risk patients
with history of prior thrombo-embolic
episodes or coronary artery disease received
only pan retinal laser photocoagulation. This
Table 1a Comparison of Time to NVI regression under three different interventions
Type of intervention Mean Time SD N F Sig. Scheffe Multiple Comparisons
(days) Pair Mean Diff p
PRP (A) 107.4 19.3 15 121.96** 0 A &B 55.94** 0
IVB (B) 51.5 14.5 13 A & C 93.30** 0
IVB + PRP (C) 14.1 4.7 10 B & C 37.36** 0
Effectiveness of intervention on IOP
Table 2a Effectiveness of treatment on IOP in PRP group
Stage Mean IOP SD N Group mean difference paired ‘t’ p
BT (A) 27.6 4.7 15 A Vs B 4.8 5.04** 0
post 2 wk (B) 22.8 4.2 15 A Vs C 4.73 3.06** 0.008
post 12 wk (C ) 22.9 5.9 15 B Vs C 0.07 0.06 0.955
** : significant at 0.01 level
Table 2b Effectiveness of treatment on IOP in IVB group
Stage Mean SD N Group mean difference paired ‘t’ p
BT (A) 27.5 4.6 13 A Vs B 4.15 5.67** 0post 2 wk (B) 23.4 3 13 A Vs C 4.62 4.21** 0.001
post 12 wk (C ) 22.9 4.6 13 B Vs C 0.46 0.61 0.553
** : significant at 0.01 level
Table 2c Effectiveness of treatment on IOP in IVB + PRP group
Stage Mean SD N Group mean difference paired ‘t’ p
BT (A) 34.8 7.3 10 A Vs B 8.4 4.71** 0.001post 2 wk (B) 26.4 5.1 10 A Vs C 12 5.75** 0
post 12 wk (C ) 22.8 3.7 10 B Vs C 3.6 4.32** 0.002
** : significant at 0.01 level
262 Kerala Journal of Ophthalmology Vol. XXI, No. 3
group also included patients with ocular
ischemic syndrome.
2) Patients who received combined PRP + IVB
were newly detected cases of vascular
retinopathy presenting to our centre with
early NVI and did not have a history of prior
laser photocoagulation.
The efficacy of combining intravitreal Bevacizumab
monotherapy with pan retinal photocoagulation in early
neovascular glaucoma prior to secondary angle closure
glaucoma alone was studied. This may not be applicable
to patients with 20 angle closure neovascular
glaucoma where prior IVB injection is necessary in
association with maximal medical therapy to control
the ocular inflammation & quieten the eye before laser
photocoagulation.
Comparison of our results with a similar study was
favourable with respect to regression of
neovascularisation of iris and angle and adequate
control of intraocular pressure. (Table : 3)
Thus combining intravitreal bevacizumab injection
panretinal laser photocoagulation can be considered
as a first line therapy for patients with early stage of
neovascular glaucoma
References
1. Oshima Y, Sakaguchi.H et al. Regression of iris
neovascularisation after intravitreal injection of
Bevacizumab in patients with proliferative diabetic
retinopathy. Am. J. Ophthalmol 2006; 142:155-8.
2. Tripathi RC, Li.J, Tripathi BJ, Chalam KV et al. Increased
levels of vascular endothelial growth factor in the
aqueous of patients with neovascular glaucoma.
Ophthalmology 1998; 105:232-7.
3. Davidorf FH, Mouser JG et al. Rapid improvement of
neovasularisation and of iris from a single Bevacizumab
injection. Retina 2006; 26:144-6.
4. Mason JO, Albert MA, Mays A et al. Regression of
neovascular iris vessels by intravitreal injection of
Bevacizumab. Retina 2006; 26:839-41.
5. Iliev MF, Domig D, Wolf – Schnurrbursch U et al.
Intravitreal Bevacizumab injection in the treatment of
neovascular glaucoma. Am.J. Ophthalmol 2006;
142:1054-6.
6. Grisanti.S. Biester S, Peters.S et al for the Tuebingen
Bevacizumab study group. Intracameral Bevacizumab
for iris rubeosis. Am. J.Ophthalmol 2006; 142:158-160.Table
3:
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son
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September 2009 Meena Chakrabarti et al. - Combination therapy in NVG 263
7. Avery RJ. Regression of Retinal and irisneovascualarisation after intravitreal Bevacizumabtreatment. Retina 2006; 26: 352 - 4.
8. Vatavuk Z, Bencic.G et al. Intravitreal Bevacizumab forNVG following CRAO. Eur.J.Ophthalmol 2007; 17:269-271.
9. Luis Amselemab, Javier Montero et al. IntravitrealBevacizumab injection in Ocular Ischemic SyndromeAm.J.Ophthalmol 2007;Vol 144(1): 122-124.
10. Ehlers J, Lam, Samuel Micheal, William Tasman et alCombination Intravitreal Bevacizumab/Pan retinalPhotocoagulation versus pan retinal photocoagulationalone in the treatment of neovascular glaucoma. Retina2008; 28(5): 696-702
264 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Ophthalmic Manifestations in Children with
Delayed Milestones- A Clinical StudyDr. Reena A. MS, Dr. Lekshmy S R MS, Dr. Lekshmi H MS, Dr. Bindu K. Appukuttan MS
ABSTRACT
A cross -sectional study of 150 children aged between 6 months and 3 years with delayed
developmental milestones was conducted at Child Development Centre, Sri Avittam Thirunal
Hospital and Regional Institute of Ophthalmology,Trivandrum over a period of 18 months.The
study aimed at identifying the various ocular manifestations in children with developmental
delay,the treatable causes of visual handicap among them and the associated antenatal and
perinatal factors. A complete systemic examination in consultation with a paediatrician and
a detailed ophthalmic evaluation including assessment of refraction was performed.The
collected data was analysed by statistical methods. CONCLUSIONS :Ocular manifestations
were present in 64 % of selected children. Refractive errors( 41.3 %), Stabismus (40 %) & Optic
Atrophy(9.3 %)were identified as the major causes of visual impairment.The chief treatable
causes were Refractive errors(41.3 %), Squint(40 %), Cataract (2.6 %) and Retinopathy of
Prematurity(4 %).Visual impairment and ocular manifestations like squint and optic atrophy
were more in children with global developmental delay.The importance of ophthalmological
examination in children with developmental delay was highlighted in the study.
Introduction
Development delay is estimated to be present in about
10% of pediatric population. Development may be
impaired due to a variety of factors like maternal,
genetic, perinatal, post-natal and social factors. Visual
development is a highly complex maturation process
involving structural and functional changes in both the
eye and the CNS.The burden of visual handicap in
childhood especially in a child with developmental
delay is of enormous importance because of the life
long impact of the handicap on other areas of
development. Early recognition of the problem may
expedite treatment or other forms of management
where the condition is not treatable. Developmental
delay may be associated with delayed visual maturation
where infants fail to develop fixation for upto 6-12
months but may later develop normal visual behaviour.
These children may have a totally normal eye but have
poor fixation due to the delay in maturation of the visual
system. In these cases, supportive treatment and
reassurance is required until the visual attention
becomes as expected.
Aim of the Study
� To study the various ocular manifestations in
children with delayed milestones.
� To find out the treatable causes of visual handicap
in these children.Regional Institute of Ophthalmology, Trivandrum
ORIGINAL
ARTICLE
September 2009 Reena A. et al. - Ophthalmic manifestations in children with developmental delay 265
� To study antenatal and postnatal factors in these
children.
� To study type of developmental delay whether
isolated or global delay.
� To highlight the importance of detailed
ophthalmic examination in children with
developmental delay.
Materials and Methods
Study Design : Cross Sectional Study
StudySetting : Child Development Centre, SAT
Hospital, Medical College,
Trivandrum, and
Regional Institute of
Ophthalmology, Trivandrum
Sample size : 150 (calculated based on
prevalance of Developmental
Delay in South Kerala)
Study period : 18 months
Study Population : Children between 6 months and
3 years with delayed developmental
milestones
Methodology
A cross- sectional study of 150 children between
6 months and 3 years of age with delayed developmental
milestones attending Child Development Centre,
SAT Hospital, Trivandrum and RIO, Trivandrum was
conducted. Proforma was prepared for recording
data of each patient separately. General examination
including systemic examination in consultation with
a pediatrician & ophthalmic examination consisting
of visual acuity assessment, anterior segment
examination, dilated fundus examination & retinoscopy
were done.
Developmental delay was assessed by Denver
Development Screening Test. The milestones were
assessed in terms of ‘Personal Social’, ‘Gross Motor’,
‘Fine Motor’ and ‘Language’. Children who did not
achieve milestones by the indicated ages were
considered to have developmental delay. Delay may be
present in either social, gross motor, fine motor or
language milestones or in all the four areas, ie, global
developmental delay.
In children <1year, visual acuity was assessed by CSM
method of fixation pattern and by indirect methods
like assessing the red reflex and resistance to occlusion.
Candy Bead test was used to assess visual acuity in
1-2 year age group or alternatively by CSM method if
needed. Sheridan Letter test was used in 2-3 year
age group. Additional investigations including baseline
blood investigations were done if indicated. Children
detected to have ocular features were managed
accordingly. Children who were found to have visual
acuity inappropriate for age or who were not fixing
and following despite normal ocular examination were
followed up after 6 months to see if there was any
improvement in visual acuity. Data collected was then
subjected to thorough descriptive statistical analysis.
Proportions of all relevant study variables were
calculated; such as demographic variables, clinical
variables such as antenatal illnesses in others, mode of
delivery of the babies, neonatal illnesses, neonatal
oxygen administration, types of developmental delay,
refractive errors, squint, nystagmus, optic atrophy,
delayed visual maturation, cortical visual impairment
Retinopathy of Prematurity, papilloedema
Results
Sex Distribution
Of the 150 children with developmental delay included
in study, 83 were males and 67 females.
Age Distribution
Children < 3 years were included in study.Among them
65 were between 6 months-1year,45 were between
1-2 years and 40 in 2-3 year age group.
Consanguinity
History of consanguinity was present only in 4 cases
while the remaining 146 were nonconsanguinous.
Antenatal Period
Antenatal period was uneventful in 133 mothers,
Pregnancy Induced Hypertension (PIH) was present in
5, fever with rashes in 5, 3 had history of trauma, 2
had Gestational Diabetes Mellitus and 2 had history of
threatened abortion.
266 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Delivery
125 were full term and 25 were preterm. Caesarian
section was mode of delivery in 23,vacuum assisted in
2 while 125 had normal vaginal delivery.
Table 1 Postnatal Period
Post Natal Period
YES NO
Neonatal Jaundice 7 143
Birth Asphyxia 25 125
Oxygen administration 12 138
Seizures 19 131
Type of Developmental Delay
Out of the 150 children, 53(36 %) showed global delay,
45(30 %) had only motor delay, 33(22 %) had delay in
motor as well as language milestones, 14(9 %) had
isolated language delay and 5 children (3 %) showed
delay in motor & personal social milestones.
Ocular Manifestations
Table 2. Ocular Manifestations
Number of Cases Percentage (%)
Ocular manifestations 97 64.6
Normal but poor VA 24 16
Normal with good VA 29 19.4
Of the total 150 children with developmental delay,
97 (64.6 %) had ocular manifestation, whereas
29 (19.4 %) had normal ocular examination and good
visual acuity, whereas 24 (16 %) had normal ocular
examination but were not fixing and following light or
had poor visual acuity [Table 2].
Distribution of Ocular Manifestations
The various ocular manifestations seen in children
with developmental delay are refractive errors,
squint, optic atrophy, delayed visual maturation,
cortical visual impairment, retinopathy of
prematurity, papilloedema, nystagmus, and cataract.
(Fig. 1)
Visual Acuity Assessment [Table 3]
Table 3 Visual Acuity Assessment
Visual Acuity Number of Cases
By CSM method
NFNF 25
GEF 1
UCF 24
CSF 16
CSF-MP 16
CSM 13
By Sheridan Letter Test
6/60 -6/36 3
6/24 -6/18 2
6/12 -6/6 30
Refractive Errors
Refractive Errors(seen in 41.3 %)) were the most
common manifestation in these children on retinoscopy.
27 children had significant hypermetropia (>+3D)
18 had myopia and 17 showed astigmatism.
Squint [Table 4]
Table 4. Stabismus
Exotropia 90(60 %)
Esotropia 19(13 % )
Latent 39(26 % )
Hypertropia 2(1 % )
Fig. 1. Aetiologic Classification
September 2009 Reena A. et al. - Ophthalmic manifestations in children with developmental delay 267
Delayed Visual Maturation
24 children who had visual acuity inappropriate for
age or were not fixing or following light despite normal
ocular examination were followed up after 6 months
to look for any improvement.It was seen that 15 of
them showed some improvement in visual acuity while
it remained status quo or worsened in 9 cases.
Vison and Delayed Milestones
Severe visual impairment (< 6/60) and majority of
ocular manifestations like squint and optic atrophy were
seen more in children with global developmental delay.
of cerebral palsy alone and found ocular abnormalities
in 28 %. Regarding the sex distribution, 55 % in this
study were males and rest 45 % were females. In study
by Wu H.J et al 68 % were males and rest females.
Mean age range 1.58+/-0.9 years.In Wu H J et al study
mean age range was 3.53+/-2.25 years.3,6
Consanguinity was seen in only 2.7 %. Antenatal history
was uneventful in 133 cases whereas 17 cases had either
history of pregnancy induced hypertension, gestational
diabetes, trauma, threatened abortion or maternal
infections. History of pre-term delivery was present in
only 25 cases.In a study by Chen et. al 13.95 % had
pre-term delivery and 13.45 % had neonatal insults. In
the post natal period, history of neonatal jaundice was
present in 7 cases (4.7 %), birth asphyxia in 25 cases
(16 %), oxygen delivery in 12 cases (8 %) and seizures
in 19 cases (12.6 %). In a study by Nielson et. al, it was
found that visual impairment was due to prenatal
factors in 11 %, perinatal factors in 6 % and postnatal
in 1.4 %.7,4
On assessing developmental delay, 36 % of cases
showed global delay, 30 % only motor delay, 22 % both
motor and language delay, 9 % isolated language delay
and 3 % showed delay in both motor and social
milestones. In the study by Chen et. al, 51.2 % had
global delay, 21.9 % had speech delay and 13.95 had
motor delay. 7
� In this study ocular manifestations were seen in
64.6 % cases. On examining 150 children, refractive
errors were seen in 62 cases (41.3 %), strabismus
in 60 cases (40 %), optic atrophy in 14 cases
(9.3 %), ROP in 6 cases (4 %), cortical visual
impairment in 9 cases (6 %), nystagmus in 7 cases
(4.6 %), cataract in 4 cases (2.6 %), papilloedema
in 1 case and delayed visual maturation in 15 cases
(10 %). In a study by Wu H J, Tsai et al, optic atrophy
and strabismus were the two most common
manifestations. Bankes et al studied 200 children
with developmental delay & found refractive errors
in 49 %,squint in 37 %, nystagmus in 7.5 % and
other features like cataract,optic atrophy and
retinopathy. 3,5
Refractive Errors(41.3 %) were the most common
manifestation in this study of which 18 % had
significant hypermetropia (> +3D) 12 % had myopia
Fig. 2. Treatable Causes
Table 5 Delayed Milestones and Ocular Manifestations
POOR VISION SQUINT OPTIC ATROPHY
GLOBAL 27 28 10
MOTOR + SPEECH 10 12 3
MOTOR 11 12 1
MOTOR + SOCIAL 2 3
SPEECH 1 4
Treatable Causes of Visual Disability
Among the various ocular manifestations, the various
treatable causes identified were refractive errors
(41.3 %), Squint (40 %), ROP (4 %) and cataract
(2.6 %) (Fig 2)
Discussion
Of the total 150 children with developmental delay
examined at CDC and RIO Trivandrum,97(64.6 %)
had ocular manifestations.A study by Wu H J etal on
41 children with developmental delay showed ocular
manifestations in 56.1%. Lagunju et al studied 149 cases
268 Kerala Journal of Ophthalmology Vol. XXI, No. 3
and 11 % astigmatism. In a similar study by Nielson
et al, 15.3 % had hyperopia>+3D, 10.8 % were myopic
and 20.6 % had astigmatism. 4
On assessing Visual Acuity severe visual impairment
(<6/60) was seen in 51 cases(34.6 %) Lagunju et al
studied 149 Cerebral palsy cases and found that
61.9 % were completely blind.Fazzi et al found that
prevalence of reduced vision in children with CNS
damage was about 86.7%. 6, 8
29 children (19.4 %) had normal ocular examination
and good visual acuity while 24(16 %)had normal
ocular examination but had poor vision or were not
fixing or following light.These children were followed
up after 6 months.On follow up,15 cases showed
improvement in visual acuity whereas 9 cases showed
no improvement.
On analyzing the severity of developmental delay and
ocular manifestations, it is found that poor vision
(ie inability to fix and follow or unsteady fixation) was
seen in 27 children with global delay and majority of
ocular manifestations like squint (28 cases) and optic
atrophy (12 cases) were seen in children with global
developmental delay. In a study by Nielson et al, it was
found that refractive errors and squint correlated with
the level of IQ 4
Conclusions
� Of the 150 children with developmental delay
examined at Regional Institute of Ophthalmology
and Child Development Centre, SAT Hospital,
Trivandrum,over a period of 18 months,
97 children (64.6 %) had ocular manifestations.
� Most common mode of presentation was that the
child was not looking at objects.
� In this study, Refractive errors (41.3 %) was
the major cause of visual impairment,followed by
squint (40 %) and optic atrophy (9.3 %).
� 10% children showed delay in visual maturation.
� Visual impairment and ocular manifestations like
Squint and Optic Atrophy were more in children
with Global Developmental Delay.
� The major treatable causes were Refractive
errors (41.3 %), Squint (40 %), Cataract (2.6 %)
and Retinopathy of Prematurity (4 %).
� Consanguinity was present in 3 % cases.
� Antenatal risk factors were identified in 10 %
cases. They were Pregnancy induced Hypertension
(3 %),Fever with rash (3 %), Trauma (2 %),
Gestational Diabetes (1 %) and Threatened
abortion (1 %).
� There was history of Preterm delivery in 17 %,
Birth Asphyxia in 16.7 %, Neonatal seizures in
12.6 %,history of Oxygen administration in 8 %
and Neonatal jaundice in 4.7 %
� Global Developmental Delay was seen in 36 %
children,whereas 30 % showed delay in motor
development, 9 % showed delay in language and
22 % showed delay in both motor and language
development.
� A full ophthalmic examination should be an
essential part of evaluation of all children with
developmental delay even when no gross ocular
abnormalities are noticed by the attending
Paediatrician. Early identification of such defects
may prove crucial in institution of therapy in all
cases which are amenable to treatment.
� Delayed visual maturation is closely associated
with developmental delay. Occasionally infants fail
to develop visual fixation for upto 6-12 months
but develop normal visual behaviour at a later
stage. Supportive treatment and reassurance is
vital in such cases.
References
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15. Sondhi N. Archer S.M, Helveston E.M: Development ofnormal ocular alignment. J Pediatric ophthalmolStrabismus 25; 210-211,1988
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17. Cole G. F.Jones RD, Delayed visual maturation. ArchDis child 1984; 59:107-110
18. Lambert S.R, Kriss A, Taylor D, Delayed visualmaturation Ophthalmol 1989;96: 524 529
19. Fern K.D and Manney R.E Visual Acuity of pre schoolchildren : a review Am J Ophtalm, physio optics 63;314-345, 1986
20. Paedriatic Ophthalmology Current aspects-KennithWyaber and David Taylor
21. “Visual Behaviours and Adaptations Associated withCortical and Ocular Impairment in Children ; Jan, J.E;Groenveld, M; Journal of Visual Impairmnet and Blindness,April 1993, American Foundation for the Blind.
270 Kerala Journal of Ophthalmology Vol. XXI, No. 3
An Outcome Analysis of Posterior Capsular
Rent (PCR) In The Hands of A Senior
Phaco SurgeonDr. Arup Chakrabarti MS, Dr. Meena Chakrabarti MS DNB, Dr. Sonia Rani John DNB, Dr. Valsa Stephen MS DO
Introduction
Posterior capsular rent is a common complication of
cataract surgery including phacoemulsification. Though
occurrence is higher with beginners, it can also occur
in the hands of a senior phaco surgeon. This study
analyses the predisposing risk factors, intraoperative
events, mode of occurrence, management strategy and
eventual outcome of Posterior capsular rent during
phacoemulsification by a senior cataract surgeon.
Materials and Methods
This was a retrospective review of 8 consecutive patients
who developed posterior capsular rent with or without
vitreous disturbance during phacoemulsification over
a period of 36 months from Dec 2005 to Dec 2008.
Posterior capsular rent was defined as an unintended
iatrogenic break in the posterior capsule occurring
during any stage of phacoemulsification cataract
surgery. Patients with zonular dialysis or preexisting
posterior capsular rent were excluded from this study.
Records of the patient and then surgical video tapes
were reviewed to accumulate data concerning the
nature, cause, surgical management and outcome of
the surgery. All surgeries were done by a single surgeon
using the Bausch and Lomb Millennium surgical unit.
Preoperative work up and preparations were routine.
All surgeries were done under topical or peribulbar
anesthesia. Direct chop or Stop and Chop were the
standard phaco techniques employed. In the event of a
posterior capsular rent, a stable anterior chamber was
maintained and if vitreous presented, an automated
anterior vitrectomy was performed by a dry or bimanual
technique. Triamcinolone acetonide staining of the
vitreous was used whenever appropriate. The data
analyzed from the case sheets and videos were : patient
profile, associated clinical features including
predisposing risk factors if any, surgical details, and
intraoperative events leading to posterior capsular rent,
management of the posterior capsular rent as well as
the postoperative outcome.
Results
Of the 8 patients who developed posterior capsular
rent, 6 were females (75 %) and 2 were males (25 %).
(Table 1). The mean age group was 72.4 yrs (Range 48
– 87 yrs). 6 of the 8 patients (75 %) had hard cataract
(Grade 4 nuclear sclerosis). One patient had an
intumescent cataract, 1 had pseudoexfoliation and one
had undergone parsplana vitrectomy. In 3 patients
visibility was poor, due to poor mydriasis in 2 and
corneal opacity in 1 (Table 2) (Fig. 1).
In 6 patients, a clear corneal incision was used.
In 2 patients a scleral tunnel incision and in 1 patient
the incision had to be extended.
In the post parsplana vitrectomy cataract, posterior
capsular rent occurred during the end stage of phaco.Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
ORIGINAL
ARTICLE
September 2009 A. Chakrabarti et al - Outcome of PCR 271
In the intumescent cataract, extension of the
capsulorhexis resulted in posterior capsular rent. Thus,
in a total of 6 cases posterior capsular rent occurred at
the end stage of phacoemulsification. Two cases had
an incomplete capsulorhexis with posterior capsular
rent occurring during irrigation / aspiration (Table 3).
In one case nucleus drop occurred requiring parsplana
vitrectomy. Anterior vitrectomy was required in 5 cases.
IOL could be inserted in the capsular bag in one case
while 6 received PCIOL in the sulcus. 1 eye was left
aphakic. Additional surgical procedures performed
included triamcinolone acetonide (Fig 2) staining of
the prolapsed vitreous to facilitate anterior vitrectomy
in 4 cases, bimanual anterior vitrectomy in 5 dry
vitrectomy (Fig 3), residual cortex aspiration with 26
gauge cannula in 8 and posterior capsulorhexis in 2.
All patients were evaluated on the same day of surgery,
at 1 week, 2 weeks and 2 months postoperatively.
Refraction was done at the 2nd week postoperatively.
On the first postoperative review 4 patients had raised
intraocular pressure which resolved in one week with
routine single topical antiglaucoma medication. Only
one patient required systemic antiglaucoma medication.
4 patients had moderate corneal edema and 2 had mild
corneal edema which resolved by the second
postoperative week. 75 % of the patients regained best
corrected visual acuity of 6/12 or more of which 83 %
Table 1: Sex Distribution
Male Female Total
No 2 6 8
% 25 % 75 % 100 %
Table 2: Associated factors
Associated Factors No
Hard cataract 6
Intumescent cataract 1
Pseudoexfoliation 1
Post PPV 1
Corneal Opacity 1
Traumatic 1
Steps of Phaco No
End stage of Phaco 6
I / A 2Fig. 3. Dry Vitrectomy
Fig. 4 (a) Intraoperative still photographs of PC rent
Fig. 2. Triamcinolone assisted anterior vitrectomy
Fig. 1. Preoperative Findings
Fig 4b. Postoperative anterior segment photographs showingwell centred PC I0L
272 Kerala Journal of Ophthalmology Vol. XXI, No. 3
had vision of 6/9 or more Fig 4 a & b. One patient who
had nucleus drop had a vision of less than 6/ 60 which
could be attributed to the preexisting corneal opacity.
Discussion
Posterior capsular rent during phacoemulsification
cataract surgery remains an important complication
because it may lead to poor visual outcome. Posterior
capsular rent though more common in beginners can
also occur in the hands of the most experienced of
surgeons.
In our study, posterior capsular rent was seen to occur
in association with certain risk factors especially with
hard cataract, intumescent cataracts, in the presence
of pseudoexfoliation and when there was poor visibility.
In uncomplicated routine cases no posterior capsular
rent occurred.
Posterior capsular rent was found to occur during
Irrigation Aspiration and end stage of phaco surgery in
our study. Studies show that posterior capsular rent is
rarer in the initial stages (capsulorhexis,
hydrodissection) and mostly appears in the middle and
final stages (phacoemulsification, Irrigation Aspiration,
IOL implantation and posterior capsular polishing) 1,2
Gimbel et al 3 reported that posterior capsular rent arose
most frequently during phacoemulsification. While Bast
et al 4 reported 72 % occurred during Irrigation
Aspiration. Taskapiliet al 5 reported that posterior
capsular rent most frequently occurs during
phacoemulsification in 59.56 % followed by Irrigation
Aspiration in 28.8 %.
Corneal edema is the most frequent cause of reduced
vision in the early postoperative period. This is generally
temporary. Varying rates of corneal edema ranging from
11.6 - 59 % had been reported 4, 5 6, 7.
High postoperative IOP is another complication
reported in patients with posterior capsular rent.
Viscoelastic material remaining in the anterior chamber,
preoperative glaucoma, trabecular blockage by
dispersed lens particle and iris pigments and mechanical
damage in the trabecular meshwork may lead to this
postoperative event. In our study 50 % developed
raised IOP compared to other studies which reported
13-40 percent 4, 6, 7
The most serious complication of posterior capsule rent
is retinal detachment. Rates of up to 3.57 percent have
been reported 4, 5, 6, 7. In our study no patient developed
retinal detachment during the followup period.
Cystoid macular edema is another complication of
posterior capsular rent which can cause decreased
visual acuity. Its incidence varies from 7.86 percent -
16.7 percent in different studies 6, 7, 8. In our study no
patient developed cystoid macular edema. This may
be due to proper management of posterior capsular
rent minimizing the vitreous loss. There may have been
cases of cystoid macular edema in our series which
eventually resolved without being diagnosed clinically.
With proper and timely management, the final visual
acuity of our patients were comparable with those in
other reports which cite 95 % of cases achieved 6 /12
or better visual acuity 3, 7,9,10. 75 % of our patients had
a visual acuity of 6/12 or more of which 83% had vision
of 6/9 or more. Thus, when properly managed a torn
posterior capsule is compatible with an excellent visual
outcome.
Early Recognition of Zonular or Posterior
Capsular Rupture
If a posterior capsular tear is not recognized in time,
subsequent intraocular maneuvers required for
phacoemulsification (viz. nuclear rotation, sculpting,
cracking) and fluctuations in anterior chamber depth
will quickly enlarge the size of the tear. The risks of
vitreous loss and dropped nucleus increase, longer the
rupture goes unrecognized. Early recognition of a
posterior capsular tear and prompt prophylactic
measures5 will prevent expansion of the tear size 5,6.
Signs of early posterior capsular tear or zonular
dehiscence6 include the following 10.
� Sudden deepening of the anterior chamber with
momentary dilatation of the pupil.
� Sudden transitory appearance of a clear red reflex
peripherally
� Newly apparent inability to rotate a previously
mobile nucleus
� Excessive lateral mobility or displacement of the
nucleus and loss of nucleus followability.
September 2009 A. Chakrabarti et al - Outcome of PCR 273
� Excessive tipping of one pole of the nucleus
� Partial descent of the nucleus into the anterior
vitreous space
Early recognition of a posterior capsular rent and proper
management ensures excellent visual outcomes.
References
1. Corey RP, Olson RJ. Surgical outcomes of cataractextracts performed by residents using phacoemulsification.J Cataract refract Surg 1998 24:66-72.
2. Ota I, Miyake S, Miyake K dislocation of the lens nucleusinto the vitreous cavity after hydrodissection. Am JOphthalmol 1996. 121:706-708.
3. Gimbel HV, Sun R, Ferensowicz et al. Intra Operativemanagement of posterior capsular tears inphacoemulsification and intraocular lens implantation.Ophthalmology 2001 108: 2186-2189.
4. Basti S, Garg P, Reddy MK. Posterior capsular dehisionsduring phacoemulsification and manual extra capsularextraction: comparison of outcomes J Cataract RefractSurg 2003; 29: 532-536.
5. Taskpili M, Engin G, Kaya G et al .Single piecefoldable acrylic intraocular lens implantation in thesulcus in eyes with posterior capsule tear duringphacoemulsification. J Cataract Refract Surg 2005; 31:1593-1597
6. Brazitikos DP, Balidis MO, Tranos P et al Sulcusimplantation three piece 6mm optic, hydrophobic,foldable acrylic intraocular lens in phacoemulsificationcomplicated by posterior capsule tear. J Cataract RefractSurg 2002;28:1618-1622
7. Yap-E-Y, Heng W J, Visual outcome and complicationafter posterior capsule rupture during phacoemulsificationsurgery. Int Ophthalmol 1999-2000;23:57-60.
8. Cruz OA , Wallace GW, Gay CA et al. Visual resultsand complications of phacoemulsification withintraocular lens implantation performed byophthalmology residents. Ophthalmology 1992:99:448-452
9. Chan FM, Mathur R, Ku JJK et al. Short term outcomesin eyes with posterior capsule rupture during cataractsurgery. J Cataract Refract Surg 2003;29:537-541
10. Blomquist PH, Rugwani RM. Visual outcomes aftervitreous loss during cataract surgery performed byresidents. J Cataract Refract Surg 2002;28: 847-852.
274 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Lens Surgery in Marfan’s syndromeDr. Somdutt Prasad MS FRCSEd FRCOphth FACS
Introduction:
Management of the subluxed lens in Marfan’s syndrome
presents one of the most challenging situations in
contemporary lens surgery. Conventional approaches
have included intracapsular lens extraction or a pars
plana lensectomy with vitrectomy. Once the lens was
removed, aphakia was corrected by glasses, contact
lenses or an iris or angle supported anterior chamber
IOL or a scleral sutured posterior chamber IOL. Marfan’s
syndrome patients are known to have an increased risk
of glaucoma as well as retinal detachment (upto 11 %
of patients with Marfan syndrome, and 8–38 % in those
who have dislocation of the lens or have undergone
lens surgery) 1. Accordingly, anterior chamber implants
are best avoided in this setting and a surgical approach
which preserves the capsular bag and avoids disruption
of the vitreous, will, at least potentially, reduce the risk
of retinal detachment subsequently.
Considerations in the surgicalapproach:
Ideally one wants to achieve lens extraction through a
continuous capsulorrhexis with preservation of the
capsular bag, re-center the bag and secure it using a
scleral fixation device and place an in-the-bag IOL,
without disrupting the vitreous body.
The anticipated challenges in these cases include:
i) Systemic considerations: These patients need
a full systemic workup, as they have associated
features of Marfan’s which may increase the risk
for an anaesthetic. They may have aortic arch or
valve anamolies or indeed have had heart valve
surgery already, in which case they may be on
Warfarin.
ii) Biometry: Eyes with severely subluxed lenses
need careful biometry to achieve a good refractive
outcome. Remember that the refraction is
influenced by the lens subluxation and may not
correlate with the predicted IOL power.
iii) Achieving a central curvilinear
capsulorrhexis: This is difficult because the lens
is unstable, the outward pull provided by the
zonules is uneven and the young patients capsule
is much more elastic than the adult, leading to a
tendency for the tear to ‘run out’.
iv) Preserving the capsular bag: Even when a
satisfactory capsulorrhexis has been achieved, the
game is not over. The bag of the Marfan’s patient
may sometimes be smaller than that of the normal
eye leading to an increased risk of tear or rip
during implantation of devices to support and re-
centre it 2.
v) Achieve lens extraction, bag re-centration and
fixation and IOL implantation without disrupting
the anterior vitreous face.
vi) Deploy techniques which reduce the risk
of late complications: posterior capsular
opacification and subluxation/dislocation of the
IOL capsular bag complex.
(1) Possible surgical strategies
In any difficult surgical situation experts will often use
different approaches to achieve the same end. ForArrowe Park Hospital, Wirral University Teaching Hospitals, NHS Foundation Trust,
Wirral, United Kingdom, sprasad@rcsed.ac.uk
OPHTHALMIC
SURGERY
September 2009 Somdutt Prasad et al. - Lens surgery in Marfan’s syndrome 275
Fig. 1. The Modified Capsular Tension Ring or the CionniRing (mCTR)
Fig. 2. The Capsular Tension Segment or Ahmed Segment(CTS)
Fig. 3. Use of the mCTR (a) a subluxed lens with temporal zonular loss (right in picture) has capsulorrhexis supported by
two ‘iris’ retractors. The bag is thus satbilised allowing completion of phacoemulsification. (b) The mCTR with adouble armed 9-0 prolene passed through its central islet is placed into the capsular bag, the anteriorly displacedcentral segment is positioned in front of the rhexis by a dialling hook, whilst a second instrument is poised to guidethe trailing end in. (c) The CIF-4 (Ethicon) needles are passed behind the iris, but in front of the anterior capsule toemerge 1.5 mm behind the limbus under a previously prepared scleral flap. This secures the mCTR and the Prolene
knot is covered by the scleral flap. A secure in-the-bag IOL is then placed.
subluxed lenses in Marfan’s patients, possible strategies
mainly follow one of two broad approaches.
One may choose to sacrifice the capsular bag, clear the
anterior chamber of all vitreous and then implant an
intraocular lens. Lens extraction can be done by an
anterior or pars plana approach if this strategy is chosen.
A pars plana approach has the advantage of allowing a
thorough vitrectomy along with a full internal search
of the peripheral retina. Whilst a complete vitrectomy
is appealing in this setting, as it would eliminate any
future vitreo-retinal traction, it is technically quite
difficult to induce a posterior vitreous separation in a
young patient, and attempts to achieve this may actually
induce retinal tears during surgery. Because of this a
deep anterior vitrectomy may be preferable. An IOL
can then be implanted in the anterior chamber. Anterior
chamber IOLs, open loop 2,3 or iris fixated (Artisan) 5
are simple and efficient techniques, but risks include
iritis, pigment dispersion, corectopia, glaucoma, and
endothelial loss. Because of these potential problems
many surgeons choose to implant a posterior chamber
lens in the ciliary sulcus, fixated by trans scleral sutures 6.
To avoid the risk of future suture breakage leading to
subluxation or dislocation of the IOL and to achieve
better centration, the elegant technique of sutureless
intrascleral posterior chamber fixation has been
developed 7,8.
Techniques which preserve the capsular bag are
intellectually more appealing, especially if the bag can
be re-centred and secured with an in-the-bag IOL
implanted. If all this can be achieved without disrupting
the vitreous body, then (at least theoretically), the risk
of complications like future retinal detachment can be
reduced. A capsular tension ring (CTR) can be used to
stabilise the capsular bag. However, CTR implantation
in eyes with a subluxated lens does not correct capsular
bag decentration 9. Lam and co authors overcame this
obstacle by implanting a CTR and then suturing it and
the capsular bag to the sclera to improve capsule
centration 10. However passing sutures through the
276 Kerala Journal of Ophthalmology Vol. XXI, No. 3
capsular bag risks tearing it, and therefore may not be
advisable. Cionni proposed the use of a modified (Fig.1)
capsular tension ring (mCTR), as this device avoided
the need to pass sutures through the capsular bag 11.
Ahmed introduced the capsular tension segment (CTS),
this smaller device is much easier to manouvre into
the bag and position as required 12 and avoids the risk
of over stretching or tearing the unstable bag. (Fig.1)
(2) Preferred surgical technique:
For many surgeons today, the preferred approach is to
go for a technique which preserves and re-centres the
capsular bag, allowing in-the-bag implantation and
fixation of the bag to the ciliary sulcus using a
combination of a CTR and a CTS.(Fig.3 a - c)
The first thing to note is that the work up to surgery in
such a case has to be meticulous, involving liaison with
all the physicians involved in the patients care and the
anaesthetist, so that a safe general anaesthetic can be
administered.
Biometry presents some unique challenges in patients
with Marfan’s syndrome. One of the most important
factors to consider when doing the biometry is which
section the axial length measurement is taken through,
i.e. the phakic or aphakic portion and then adjusting
your instrument accordingly, to take into account the
presence or absence of lens material. Depending on the
extent of the subluxation you may need to consider
dilating the patient in order to ensure you are definitely
aiming the beam through the correct portion. If using
the A-Scan ultrasound to measure axial length, you will
be able to confirm the position of the probe by looking
for the echo corresponding to the presence of the lens
boundaries. Using a case of Marfan’s as an illustrative
example: A 13 year old had bilateral subluxed lenses
had an undilated refraction of R:-30.00/+6.00x115 L:-
24.00/+5.00x60. When dilated and using his aphakic
portion his refraction was R:+8.00/+3.50x120
L:+9.00/+2.50x80 achieving the same level of vision
with both prescriptions. His phakic axial length was
RE:26.49, LE:26.01 and aphakic axial length RE:26.36,
LE:25.96. As you would expect the measurement should
be comparable regardless of which portion it’s taken
through, if the instrument is correctly programmed. The
left eye was operated on using this measurement and has
a deviated post-operative spherical equivalent of -0.68DS.
The lens chosen should be a 3 piece lens with a 360
degree square edge, This reduces the risk of post-
opeartive posterior capsule opacification and the 3 piece
designs allows for resturing into the scleral sulcus, should
late breakage of the suture lead to IOL displacement in
future years 13, 14. I prefer a B&L (Bausch & Lomb)
L161AO which is a 3 piece lens with a 360 degree square
edge and an aspheric design. The Sofport injection
system, used for injecting this lens allows it to come
out into the capsular bag in a fairly flat disposition,
minimising the potential for destabilising an already
unstable bag during IOL implantation.
An illustrative case described below is used to
demonstrate the steps in the technique. Surgery is
usually done under a general anaesthetic.
(3) Case Presentation
A 12 year old boy with known Marfan’s syndrome was
referred by a paediatric ophthalmologist who had been
seeing him from the age of two years. He had managed
reasonably with spectacle correction, maintaining good
vision in both eyes. More recently the subluxation in
the right eye had progressed to the point that his vision
was reduced to 6/24 (BCVA). On presentation his vision
was 6/24 in the right eye (-24.50 DS / +9.00 DC x 92
½ and 6/9+3 in the left eye (-3.00 DS / +3.00 DC x
95). In addition he was being bullied at school and
children kept stealing his glasses. Systemic workup
included aortic valve problems for which he was on
Atenolol and antenatal hydronephrosis both of which
were being managed by appropriate specialists. On
examination the right lens was subluxed markedly with
edge of the lens passing through the centre of the pupil
and the left lens subluxed to a lesser extent. Rest of the
eye examination was unremarkable with normal
intraocular pressures, no vitreous in the anterior
chamber and normal peripheral retinal examination.
Axial length measurements through the phakic portion
was RE: 25.50, LE:21.46 and through the aphakic
portion RE:25.29, LE:21.25. Using the aphakic
measurement we calculated a +18.00 Diopter B&L
(Bausch & Lomb) L161AO IOL for emmetropia when
implanted into the capsular bag
Figure 4a shows the pre-operative situation, with a
subluxed and decentred lens. A fornix based
conjunctival flap is made in the zone of maximum
September 2009 Somdutt Prasad et al. - Lens surgery in Marfan’s syndrome 277
Fig. 4b
Fig. 4c
Fig. 5a Fig. 5b
Fig. 6a Fig. 6b
Fig. 6c
Fig. 4a
Fig. 7
subluxation, followed by the creation of a partial
thickness scleral flap with its base towards the fornix.
The scleral dissection begins at the limbus and extends
peripherally for about 3mm. It is 4 mm wide (Fig 4b).
Two paracentecis incisions are made on either side of
this scleral flap and flexible ‘iris’ retractors are
prepositioned to support the capsulorrhexis as it is later
developed (Fig. 4c).
The capsulorrhexis is begun close to the iris edge at
12 o’clock as this is the centre of the lens (Fig 5a).
Viscoat is used to fill the anterior chamber and
tamponade the vitreous face. The capsulorrhexis is
developed, taking care to keep a 3 mm distance from
the lens equator (this facilitates later placement of CTR
and CTS; an adequate anterior capsule is necessary to
avoid the CTR or CTS flipping forward, out of the bag
and into the anterior chamber later in the operation.).
The tear is developed a few mm beyond the area where
the iris retractor is poised to engage it, and once the
tear is well clear, the ‘iris retractor is used to engage
the edge of the rhexis and gently draw the lens equator
out to the periphery thus helping to re-centre the
capsular bag. The rhexis is developed further and the
second iris hook engaged and drawn centripetally
further re-centres the capsular bag allowing the superior
part of the capsule to come into view (Fig 5b). The
rhexis can then be completed. Gentle hydrodissection,
with small slow waves of fluid is then done.
A CTR is then inserted into the bag to stretch it
(Fig 6a), and thus allow phacoemulsification without
the bag flopping onto the probe, as is possible in a
largely unsupported bag. Once lens matter has been
removed a CTS with a 9-0 prolene on a double armed
Ethicon CIF-4 needle passed through the central islet is
guided into the capsular bag (Fig 6b). The IOL is then
implanted into the capsular bag (Fig 6c) and the needles
are passed in front of the anterior capsule but behind
the iris to emerge about 1.5 mm behind the limbus
under the previously designed scleral flap. The iris
retractors are then released allowing the surgeon to
judge the position of the capsular bag better. The suture
is tightened (Fig 7) and incisions sutured after removing
viscoelastic. Intracameral Cefuroxime was injected at
the end for endophthalmitis prophylaxis.
Two weeks post operatively vision had recovered to
6/18 unaided, 6/12 with a pinhole and at six weeks
278 Kerala Journal of Ophthalmology Vol. XXI, No. 3
vision was 6/6 with minimal refraction (-1.00 DS /
+1.25 DC x 180). The IOL was well centred.
He requested surgery for his other eye.
(4) Surgical pearls
i) Unstability of the anterior chamber must be
avoided at all cost, mainly to avoid vitreous
coming forward. Meticulous fluid – viscoelastic
exchange technique avoids the capsular bag
diaphragm flopping forward and backward. This
means that every time the phaco probe has to be
removed from the eye, this is done by stopping
aspiration, but with irrigation continuing,
viscoelastic is injected through a side port to
support the anterior chamber. Whilst viscoelstic
is being injected, one gradually eases off the
irrigation, and then the probe can be safely
withdrawn whilst maintaining a deep anterior
chamber, and preventing the capsular bag from
coming forward.
ii) Instead of conjunctival dissection and a scleral
flap, a 600 micron limbal incision is made with a
guarded diamond blade in the region of maximal
lens edge decentration. This incision is similar to
a limbal relaxing incision. A crescent blade is then
used to dissect a 4 mm (wide) x 3 mm deep (from
limbus to periphery), partial thickness scleral
pocket. This allows the prolene knot to be buried
under sclera, with conjunctiva undisturbed.
Moreover as the sides of the ‘pocket’ are attached,
there is no real risk of scleral ‘flap’ contraction in
the future.
iii) When the lens matter is soft (as in a young
patient), most of the surgery is done through two
paracentesis incisions (about 1mm each), with all
the lens matter removed using bimanual
irrigation-aspiration (no phacoemulsification).
This allows for greater stability and reduces risk
of vitreous disturbance. Only when all lens matter
has been removed a 3 mm incision is made to
enable placement of a CTS and then the IOL.
Conclusion
I have here presented the evolving techniques for lens
surgery in Marfan’s syndrome. Whilst some aspects are
debatable, I believe that the combination of a CTR and
a CTS fixated transclerally under a scleral pocket allows
secure in-the bag IOL placement and potentially reduces
the risk of future complications. Meticulous surgical
technique is essential to avoid disrupting the capsular
bag and disturbing the anterior vitreous face. When
this is done excellent visual and anatomic outcomes
are attained. At least potentially, this should reduce the
risk of long term complications, time will tell if this
potential is achieved. In a personal series of eleven
consecutive Marfan’s eyes operated on over the last
two years, in the bag placement with a well centred
bag and secure fixation of a capsular tension segment
using a prolene suture was achieved in all cases with
good visual outcomes.
Reference:
1. Maumenee IH. The eye in the Marfan syndrome. Trans
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2. Bahar I, Kaiserman I, Rootman D. Cionni endocapsular
ring implantation in Marfan’s Syndrome. Br J
Ophthalmol 2007;91;1477-1480
3. Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular
lens implantation in the absence of capsular support; a
report by the American Academy of Ophthalmology
(Ophthalmic Technology Assessment). Ophthalmology
2003;110:840–59.
4. Morrison D, Sternberg Jr P, Donahue S. Anterior
chamber intraocular lens (ACIOL) placement after pars
plana lensectomy in pediatric Marfan syndrome. J
AAPOS 2005;9:240–2.
5. Lifshitz T, Levy J, Klemperer I. Artisan aphakic
intraocular lens in children with subluxated crystalline
lenses. J Cataract Refract Surg 2004;30:1977–81.
6. Tsai YY, Tseng SH. Transscleral fixation of foldable
intraocular lens after pars plana lensectomy in eyes with
a subluxated lens. J Cataract Refract Surg 1999;25:
722–4.
7. Scharioth GB, Pavlidis MM. Sutureless intrascleral
posterior chamber intraocular lens fixation. J Cataract
Refract Surg 2007;33;1851-1854
8. Badon ACJ, Scharioth GB, Prasad S. Intrascleral
Sutureless Posterior Chamber Intraocular Lens Fixation
Using Scleral Tunnels. Techniques in Ophthalmology
2009 (in press)
9. Dietlein TS, Jacobi PC, Konen W, et al. Complications
of endocapsular tension ring implantation in a child
with Marfan’s syndrome. J Cataract Refract Surg
2000;26:937–40.
10. Lam DSC, Young AL, Leung ATS, et al. Scleral fixation
of a capsular tension ring for severe ectopia lentis. J
Cataract Refract Surg 2000;26:609–12.
September 2009 Somdutt Prasad et al. - Lens surgery in Marfan’s syndrome 279
11. Cionni RJ, Osher RH, Marques DM, et al. Modifiedcapsular tension ring for patients with congenital lossof zonular support. J Cataract Refract Surg2003;29:1668–73.
12. Hasanee K, Ahmed II. Capsular tension rings: updateon endocapsular support devices. Opthalmol Clin North
Am 2006;19;507-19
13. Buckley EG. Hanging by a thread: the long-term efficacyand safety of transscleral sutured intraocular lenses inchildren [an American Ophthalmological Societythesis]. Trans Am Ophthalmol Soc. 2007; 105:294-311
14. Por YM, Lavin MJ. Techniques of intraocular lenssuspension in the absence of capsular/zonular support.Surv Ophthalmol. 2005;50: 429-462
In a lighter vein
MEMORY
RRV
I had previously written in this column that the most essential quality for a medicalpractitioner is patience. It is true, alright. But equally important is another one –good memory for names and faces. At least some of your patients expect you toremember them when they come back to you – six years after their previous visit.And are very gratified if you do. Some of them even feel insulted if you don’t.
In my school days we had our family doctor who used to manage anything fromallergy to angina and pruritis to pregnancy. Every time one of the family memberswent to him, he used to ask about the others; their marriages; children’s educationalproblems etc. And he never made a mistake. I always used to wonder how he managedto remember each one of his patients with their myriads of profiles and problems.Of course he had a good memory. But when I myself became a doctor, I happened toask him as to his prodigious reminiscental capabilities he laughed and said: “Oh! Imake small notations on the edge of the prescription as to the job or class or wife’sname etc.”
I tried to emulate him when I started practicing. But my memory was never as good;and I couldn’t remember what my notations stood for.
The problem is worst when you think you remember the face but can’t put a name toit. And the patient talks on familiarly and has not brought the old prescription.When the time comes to write the prescription you use various techniques. One is toask him/her what his/her FULL name is. If it is such small and simple name like“Unni”, you are in trouble. Or you ask him/her what the OFFICIAL name is. If theanswer is ‘It is the same one’, again you are in trouble. May be you can ask what his/her initials are. Most of them will say the name along with the initials. Again it won’thelp if he/she answers simply “P.K.” or “C.T.” With ladies I try another ruse. I askwhat their husband’s name is and prefix a ‘Mrs.’; but you are in a fix if she demurelysay “Oh, doctor, but I am not married.” So now a days I take the bull by the hornsand say: “Sorry, but I can’t remember your name”. With young boys or girls I mayadd, “How you have grown up! I couldn’t recognise you”. Do not try this with olderwomen Instead, say: “You appear younger, I couldn’t recognise you.” Fortunately inmy experience, men do not mind being asked the name visit after visit as much as thefairer sex.
A couple of days back I asked a female patient her name and heard the familiar ‘howcan you forget me’ thing. But considering that she was clad in a ‘burkha’ with a clothmesh in front of her eyes, I felt vindicated.
280 Kerala Journal of Ophthalmology Vol. XXI, No. 3
The Eyesi: Ophthalmic Surgical SimulatorDr. Meena Chakrabarti MS, Dr. Sonia Rani John DNB, Dr. Arup Chakrabarti MS
In recent years, the medical community has benefited
from technological advances that simulate surgical
environments. Ophthalmologists now have access to
commercially available virtual reality systems, including
the Eyesi Ophthalmic Surgical Simulator (VRMagic,
Mannheim, Germany). Fig (1)
The ophthalmic training system is based at the Mayo
Clinic’s Multidisciplinary Simulation Center
(www.mayo.edu/simulationcenter), a 10,000-square
foot clinical training facility dedicated to simulation-
based clinical education and research.
Gone are the days when residents first learned the basics
of handling intraocular instruments and a surgical
microscope in the OR or a variable wet lab environment.
Instead, they now complete a structured curriculum
that combines one-on-one instruction and independent
study with the Eyesi simulator. Instructors create
courses that residents repeat and practice until they
achieve passing scores. The surgeons-in-training then
advance to the Eyesi system’s higher levels of difficulty
until they master all of the simulator’s training tasks.
Residents are enthusiastic about the technology and
its constant availability (24 hours a day, 7 days a week)
(Fig 2).
In studies, the Eyesi Ophthalmic Surgical Simulator
demonstrated construct validity (the ability to reliably
distinguish between novice and expert surgeons) for
training tasks in the posterior and anterior segments2, 3.
The device’s stereoscopic view and foot-pedal controls
are excellent proxies for the “real” environment of
cataract surgery.
VRMagic originally developed the Eyesi system to
simulate vitreoretinal surgery. Recently, however, the
company added a training module for the anterior
segment (Figure 1). In addition to simulating the use
of forceps, precise navigational tasks, the capsulorhexis
formation, and phacoemulsification, the Eyesi’s anterior
segment module evaluates the user’s performance and
measures instructor-defined, standardized surgical
tasks in a virtual environment 1.Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
Fig. 1: The Eyesi: Ophthalmic Virtual Reality SurgicalSimulator.
O P H T H A L M I C
INSTRUMENTATION
September 2009 Meena Chakrabarti et al. - The Eyesi: Ophthalmic Surgical Simulator 281
Using the anterior segment training module and the
built-in forceps tool, residents learn how to manipulate
instruments in the eye, pivot them at the wound, and
avoid inadvertently injuring the cornea or crystalline
lens. The simulator’s scoring system rewards users for
the efficiency of their intraocular manipulations and
the precision with which they complete their tasks. The
capsulorhexis training module is actually more
challenging than “the real thing,” an acceptable and
desirable quality for a surgical training system.
The posterior segment training modules simulate the
manipulation of forceps, the precise movement of
instruments in the posterior segment, antitremor
training/control, and procedures such as vitrectomy,
epiretinal membrane peeling, and internal limiting
membrane peeling. The Eyesi’s retinal simulations can
“suspend reality” quite effectively. For example,
inexperienced surgeons become so engrossed in
virtually peeling an epiretinal membrane that they
actually start sweating.
Hands-on experience in traditional surgical wet labs is
still the gold standard for training residents to perform
corneal and scleral suturing techniques. Currently
available surgical simulators do not attempt to replace
the experience of working with real cadaveric eyes.
Instead, the simulator provides a realistic, repeatable,
and measurable intraocular surgical environment that
is difficult to duplicate in the traditional wet lab setting.
The Eyesi’s on/off setup eliminates the significant time
and effort typically involved in preparing and
dismantling a wet lab. In addition, the surgical
simulator measures and documents the user’s efforts
and performance.
Depending on which module is used during a training
session, the system tracks and scores up to 74 different
performance variables (Table 1). The Eyesi’s screen
displays the data for each trial, which can also be
summarized and graphed at the end of each simulated
surgical session or exported to a spreadsheet program
for statistical analysis. By allowing residents to
repeatedly perform standardized tasks and measuring
their performance in a realistic environment, the Eyesi
system helps us train surgeons to perform cataract
surgery safely and competently without putting patients
at risk.
Surgical training content for EYESi is organized in
software modules. Training is available for cataract and
vitreoretinal surgery. The ever expanding menu of
surgical modules now offers procedures like
Capsulorhexis and Phaco-emulsification or Posterior
Hyaloid Detachment and ILM Peeling. Each training
module includes various tasks with increasing difficulty
levels.
As EYESi is designed to integrate into a residency
program curriculum the system allows for
customisation. Therefore medical educators can create
courses from the assorted modules and levels of
complexity that exist within the surgical training
modules.
The ability to define training content ensures medical
educators can set up individual curricula to meet the
needs of the trainee relative to the trainee’s current
Fig. 2. An Eyesi training session in progress.
stage of skill and experience. Thus dedicated courses
can use easy or difficult levels from the selected training
modules so that both novices and advanced trainees
can refine their skill level.
EYESi provides the medical educator with detailed user
and group management so that a course can be assigned
to an individual trainee or groups of trainees.
After courses are build and integrated into the residency
curriculum a medical educator would logically want to
monitor each trainee’s development. EYESi offers
detailed performance evaluation and all data for a
trainee can be exported via USB as user friendly spread
sheets or graphs.
To further support medical educators EYESi offers a
recorder playback functionality so that an instructor
282 Kerala Journal of Ophthalmology Vol. XXI, No. 3
can review any given simulation session and provide
feedback to the trainee. All videos and screenshots can
easily be exported via USB for later use. An identical
curriculum can be used over time to measure the
learning curve or to compare skill levels of students.
EYESi cataract
For training of anterior segment surgery the EYESi
platform is equipped with a cataract surgery interface
which includes a head with a cataract eye interface,
the cataract instrument set, footpedals and the
corresponding system software. The simulation can be
configured easily for superior or temporal access to the
patient’s eye; the cataract eye is prepared for
corresponding incisions.
According to many instructors and trainees, mastery
of the capsulorhexis and phaco-emulsification are
amongst the most difficult steps in cataract surgery. In
a capsulorhexis the main difficulty lies in controlling
the delicate capsule tissue to tear in the desired manner.
Furthermore the trainee must learn this complex manual
skill within a confined space of the anterior chamber.
EYESi cataract offers extensive training of the
capsulorhexis. It even allows for the training of
complications so that trainees master what to do when
the rhexis runs outwards.
In learning to perform phacoemulsification the
challenge rests in understanding and controlling the
complex physics of the phaco device.
The phaco training modules offer a safe environment
to experiement with phaco machine settings and to
explore the effects of parameter changes. In practical
terms this means a trainee can cause unwanted events
like surge and chatter and learn how phaco parameter
adjustments can eliminate these occurrences.
A step-by-step approach to the “Divide and Conquer”
technique allows for stress free and lasting acquisition
of the required surgical skills. EYESi also enables a
trainee to now pool all the manual skills together that
make up modern phaco techniques as the simulation
requires coaxial use of instruments, use of the
microscope foot pedal, and modulation of the desired
phaco parameters with a phaco foot pedal.
Table: 1 Performance variables tracked and scoredby the Eyesi System
1. Educational open forceps insertion and removal
2. Nonhorizontal instrument insertion and removal
3. Interacting out of focus and light cone
4. Average radius of capsulorhexis
5. Decentration and overall irregularity of capsulorhexis
6. Deviation of capsulorhexis’ radius from target value
7. Instrument insertions
8. Remaining aqueous humor
9. Efficiency Time (after first interaction)
10. Ultrasonic energy
11. Viscoelastic injection
12. Injury Incision stress
13. Injured cornea and lens area
14. Lens displacement
15. Damaged zonular fibers
16. Iris contact
17. Anterior chamber pressure too low
18. Ultrasonic leakage
19. Emulsification of adjacent cortex
20. Cornea and capsule damaged by ultrasonic energy
21. Anterior and posterior capsule torn
22. Target Remaining objects
22. Progress
23. Capsulorhexis completed
24. Lens cracked/removed
Most medical educators and trainees know that learning
to see through a microscope with both hands and both
feet working all at the same time in a deliberate and
harmonious manner takes considerable practice. EYESi
provides a better way to train for anterior segment
surgery as risk is removed when a patient is eliminated
from the training loop and a trainees can safely practice
critical parts of cataract surgery to mastery.
Fig. 3. The Cataract Module
September 2009 Meena Chakrabarti et al. - The Eyesi: Ophthalmic Surgical Simulator 283
EYESi vitreoretinal
For training of posterior segment surgery the EYESi
platform is equipped with the vitreoretinal surgery
interface which consists of a head with the vitreoretinal
eye interface, a vitreoretinal instrument set, foot pedals
and the corresponding system software.
medical educators to use the system as a complete
training platform.
EYESi’s system software enables medical educators to
seamlessly integrate their own courseware into the
platform. Through the secure administration functions
individual courses can be compiled and complemented
with academic text, still images and high resolution
digital video footage. Powerpoint presentations can be
imported and presented on the graphical user interface
of the EYESi simulator. This allows trainees to study
medical background information and then observe
demonstrations depicting how their mentors perform
Fig. 4. A vitreoretinal training session in progress.
Most everyday realities of microsurgery in the complex
vitreoretinal environment are represented in EYESi.
The EYESi microscope renders a stereoscopic view
identical to the real OR microscope. The trainee is
required to establish suitable visualization via the
microscope foot pedal’s zoom, focus, and X/Y controls.
Experienced retina surgeons know observing the retina
requires a BIOM/ SDI hardware so this too is integrated
into the microscope setup.
Assorted training modules are available for EYESi
vitreoretinal. Training sessions include tasks like
inducing posterior hyaloid detachment and performing
peripheral vitrectomies, peeling the internal limiting
membrane (ILM) or the removal of epiretinal
membranes.
To aid trainees in refining precise manual dexterity skills
associated with vitreoretinal surgery EYESi provides a
virtual surgical instrument tray. In the course of
performing virtual surgery a trainee will use an
illumination probe in their non-dominate hand. As in
real retinal surgery EYESi realistically enables the
surgeon’s dominant hand to alternate between
instruments such as vitrector, endolaser, forceps, scissors
etc.
Trainees acquire expert status during training in a
variety of ways. EYESi therefore was developed to allow
Fig. 5. Macular translocation.
any given procedure. If the goal is teaching the
capsulorhexis a trainee can read about the task, observe
how the task is done, and then complete the task in
virtual reality till mastery of the skill is known to have
been obtained.
With the option to combine the practical surgical
training with multimedia presentations of medical
knowledge EYESi represents the modern way of
teaching surgical skills.
Conclusion
Keeping up to date with the rapid advances and
complexity of modern intraocular surgery is a
challenging but ultimately satisfying and rewarding
endeavor. Surgical simulators based in virtual reality
allow residents to develop and hone their surgical skills
so that they provide patients with the safest and highest-
quality surgical outcomes possible. Currently, a barrier
to the Eyesi’s broad adoption appears to be the system’s
cost (between $100,000 and $200,000, depending on
optional features and the date of purchase)
284 Kerala Journal of Ophthalmology Vol. XXI, No. 3
References
1. EYESi Ophthalmosurgical Simulator user guide.
Mannheim, Germany: VRMagic; 2008.
2. Rossi JV, Verma D, Fujii GY, et al. Virtual vitreoretinal
surgical simulator as a training tool. Retina.
2004;24:231-236.
3. Mahr M, Hodge D. EYESI Ophthalmic Surgical
Simulator anterior segment anti-tremor and forceps
training module construct validity: attending versus
resident performance. J Cataract Refract Surg. In press.
To view a video of a simulated capsulorhexis rescue
performed on the Eyesi Ophthalmic Surgical Simulator,
visit the ESCRS’s Video on Demand Web site at
www.conference2web.com/escrs/Videos or aspx#
VRMagic’s Web site at www.vrmagic.com/downloads/
eyesi/videos/ESCRS%20Mahr.zip
September 2009 SR John et al. - Nepafenac 285
NepafenacDr. Sonia Rani John DNB, Dr. Meena Chakrabarti MS, Dr. Arup Chakrabarti MS
surgery and the other is cataract or other intraocular
surgeries. With refractive surgery, NSAID drops are
particularly effective in reducing discomfort both during
and after the procedure. To a lesser extent, they also
reduce inflammation in the eye related to refractive
surgery, particularly in the cornea and conjunctiva.
With cataract and intraocular surgery, topical NSAIDS
offer several benefits. The goals of topical prophylactic
nonsteroidal anti inflammatory drug treatment include
the prevention of intraoperative miosis 3, management
of postoperative inflammation 3, prevention or
treatment of CME 3,4 and reduction of ocular pain 5.
They lessen the patient’s discomfort during the
procedure, which is especially important when using
topical anesthesia in cataract surgery. NSAID also help
maintain pupillary dilation during cataract surgery,
which has been shown to lower the rate of
complications. They help in controlling inflammation
in the first few days after surgery, as measured by the
presence of cells and flare in the anterior chamber.
Finally, NSAIDs inhibit the development of cystoid
macular oedema (CME), which usually occurs 4 to 6
weeks after cataract surgery. Even after a perfect
cataract surgery with the most modern techniques and
the best instrumentation, as many as 12 % of patients
may develop some CME and the use of an NSAID may
significantly reduce this complication.
Four topical ocular NSAIDS are currently approved by
the U.S Food and Drug Administration (FDA) for the
treatment of postoperative inflammation after cataract
surgery. They are Acular (ketorolac 0.5 %), Xibrom
(bromfenac 0.09 %), Voltaren (diclofenac 0.1 %) and
Nevanac (nepafenac 0.1 %).
Ocular inflammation is a common result of cataract
surgery, producing pain and photophobia in many
patients and potentially leading to serious complications
including increased intraocular pressure, posterior
capsule opacification, cystoid macular oedema and
decreased visual acuity. Steroidal agents have been the
standard treatment for ocular inflammation in the past
while the use of topical NSAIDS has increased over the
past two decades. Clinical evidence suggests that the
combined use of NSAIDS and steroids is synergistic 1.
In fact it has become the standard of care to use a
regimen of NSAIDS and steroids before and after
cataract surgery 2.
Prostaglandins are involved in human intraocular
inflammation and released in response to ocular
trauma, including surgery. When present following
trauma, intraocular surgery, or in association with
uveitis, they may contribute to disruption of blood –
ocular barriers and the generation of macular edema.
During cataract surgery, arachidonic acid is released
from phospholipids of cell membranes to provide the
precursor for prostaglandin synthesis. Corticosteroids
affect the cascade by attenuating the expression of
inflammatory mediators that initiate activation of
phospholipase and the release of arachidonic acid thus
limiting prostaglandin production. NSAIDs exert their
effects further downstream of the cascade, directly
inhibiting cylco-oxygenase and the production of
prostaglandins.
There are 2 main settings of ocular surgery in which
ophthalmologists use topical NSAIDS. One is refractive
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
OCULAR
PHARMACOLOGY
286 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Nepafenac (Nevanac, Alcon Laboratories) is a novel
topical nonsteroidal anti-inflammatory drug, which is
the only prodrug NSAID, having less anti-inflammatory
activity without conversion to its more active state 6.
Each ml of Nevanac (0.1 %) suspension contains 1 mg
of nepafenac. Nepafenac is designated chemically as 2
–amino 3-benzoylbenzene acetamide with an empirical
formula of C15
H14
N2O
2.
Nevanac Ophthalmic suspension is the first and only
topical NSAID structured as a prodrug. This unique
design allows for target specific activity, because its
efficacy is maximized at the intraocular sites of most
concern to ophthalmologists. Once Nevanac penetrates
the eye, intraocular hydrolysis converts the nepafenac
molecule into a potent cyclooxygenase inhibitor called
amfenac, an active drug that has strong anti-
inflammatory capabilities.
Unlike conventional NSAIDs, the active forms of which
tend to accumulate on the ocular surface and decrease
in activity and concentration as they penetrate the eye,
Nevanac is specially designed to maximize intra ocular
efficacy. Its unique prodrug structure allows Nevanac
to achieve optimal distribution through the cornea into
the iris / ciliary body and retina / choroid , providing
superior inflammation suppression. At the same time,
this rapid and targeted distribution may minimize
tolerability issues commonly noted with conventional
NSAID therapies, because the drug doesn’t overload
the ocular surface.
Nevanac uniformly inhibits all prostaglandins of the
iris / ciliary body, retina, PGE2 synthesis, and the
breakdown of the blood–aqueous barrier. Compared
with conventional NSAIDs such as diclofenac,
nepafenac 0.1 % is superior in blocking the production
of prostaglandins in an uniform manner 7. Studies 8
show that nepafenac 0.1 % inhibits 95 % of
prostaglandin formation by the iris / ciliary body within
80 minutes after topical dosing, compared with
diclofenac’s 53 % 9. This fact has important clinical
implications in terms of potential differences in efficacy
between Nevanac and conventional NSAID therapies.
It is believed that CME is caused by surgically induced
prostaglandin formation in the aqueous and vitreous
and / or by the breakdown of the blood – aqueous and
blood – retinal barriers. Even mild CME damages the
retinal pigment epithelium. Such damage is irreversible,
because these cells do not regenerate. Therefore, any
retinal swelling can have a lasting negative impact on
a patient’s vision.
Due to their mechanism of action, NSAIDs have been
shown to be a good line of defense against CME.
Obviously, it is key that the NSAID selected reaches the
target tissues to provide therapeutic anti-inflammatory
activity and thus prevent the processes described.
The target- specific activity of Nevanac hold great
potential for the superior prevention of post-cataract
complication such as CME. Because the highest
concentration of Amfenac occurs in the choroid and
retina, the agent not only decreases inflammation in
the anterior chamber, but should also lower the patient’s
risk of developing CME. Studies 10,11 have shown that
nepafenac 0.1 % inhibits prostaglandin formation in
the vitreous, whereas conventional NSAID such as
diclofenac and ketorolac fail to do so. A study 12
evaluating the suppression of prostaglandin synthesis
of nepafenac 0.1 % versus diclofenac in the iris/ ciliary
body and the retina / choroid showed that a single
topical dose of nepafenac 0.1 % significantly inhibited
prostaglandin synthesis in the iris/ciliary body and
retina choroid. Efficacy was sustained for 6 hours in
the iris / ciliary body and for 4 hours in the retina/
choroids. In contrast, for diclofenac peak suppression
of prostaglandin activity in the iris/ciliary body was
sustained for 20 minutes, with only minimal inhibition
of prostaglandin synthesis observed with diclofenac in
the retina / choroid.
Because nepafenac is a neutral molecule, it has been
hypothesized to have greater corneal permeability than
other NSAIDS which have acidic structures. In a vitro
study of rabbit tissue, nepafenac had 6 fold greater
corneal penetration than diclofenac as well as faster
rate of penetration 13. Similarly in another study,
nepafenac aqueous humor Cmax
values were 3.6 fold
higher than those of ketorolac despite having a starting
concentration 4-fold (0.1 % versus 0.4 %) 14. Nepafenac
Cmax
values were more than 8 fold higher than those of
bromfenac, despite having similar starting
concentrations (0.1 % versus 0.09 %). Thus the results
in various studies support the fact that the prodrug
nepafenac has faster corneal penetration rate than other
conventional NSAIDs.
September 2009 SR John et al. - Nepafenac 287
Intraocular drug concentrations are expected to
correspond with the anti-inflammatory efficacy of a
drug. The near –maximum concentrations of amfenac
is maintained longer than those of Ketorolac suggesting
that Nevanac may have a prolonged duration of action
relative to other drugs in this class. This may be due to
nepafenac prodrug structure which allows it to rapidly
traverse the cornea, reaching Cmax
in the aqueous humor
within 30 minutes.
Nepafenac is a non steroidal anti-inflammatory
pro-drug that potentially inhibits Cox-1 and Cox-2
activity ex vivo following topical ocular administration.
Nepafenac demonstrates low intrinsic cyclo-oxygenase
inhibitory activity in vitro, yet exhibits in vivo efficacy
equal to that of diclofenac in models of anterior segment
ocular inflammation. In addition to its anterior segment
efficacy, nepafenac exceeds diclofenac in its ability to
reduce posterior segment ocular inflammation.
Nevanac has been tested in various concentrations
(upto 15 times its commercial concentration ) and in
short – as well as – long term settings and it was found
to be safe and well tolerated 15,16. Nepafenac penetrates
the target intraocular tissues faster than any other
topical NSAID, thus providing greater efficacy on a
clinical basis. Once inside, it has rapid conversion and
therapeutic onset and a very high level of tissue
concentration. Studies show that its rate of systemic
absorption in approximately 1700 times less than that
of an oral dose.
Nevanac hold the promise of fast, pain-free visual
recovery without the potential common side effects
noted with conventional NSAID therapies. As
mentioned previously, its unique prodrug formulation
ensures optimal intraocular distribution 17 with superior
inflammation suppression. The superior bioavailability
of Nevanac to the retina / choroid also ensures an
unsurpassed potential for preventing CME after cataract
surgery.
Nevanac suspension, which was filed with the FDA for
the treatment of inflammation following cataract
surgery, will provide a novel, target- specific structure
that optimizes penetration throughout the relevant
ocular tissues to deliver enhanced, longer –lasting anti-
inflammatory efficacy all the way to the retina / choroid
which is of particular relevance to ophthalmic surgeons.
References
1. Flach AJ, Nonsteroidal anti-inflammatory drugs.In ; Tarman W, ed, Duances Foundation of ClinicalOphthalmology Philadelphia, PA, Lippincott 1994; Vol3; Chapter 38.
2. O, Brien T.P. Emerging guidelines for use of NSAIDtherapy to optimize cataract surgery patient care. CurrMed Res Opin 2005;21:1131-1137; erratum, 1431-1432.
3. Flach AJ. Topical nonsteroidal anti-inflammatory drugsin Ophthalmology. Int Ophthalmol Clin 2002; 42 (1);1 -11.
4. Miyake K, Marnda K, Shirato S, et al. Comparison ofdiclofenac and fluorometholone in preventing cystoidmacular edema after small incision cataract surgery; amulticentred prospective trial. Jpn J Ophthalmol 2000;44:58-67.
5. Price MO, Price FW. Efficacy of topical ketorolactromethamine 0.4 % for control of pain or discomfortassociated with cataract surgery. Cure Med Res Opin2004; 20:2015-2019.
6. Gamache DA, Draff G, Brady MT, et al. Nepafenac, aunique non steroidal prodrug with potential utility inthe treatment of trauma-induced ocular inflammation.Assessment of anti-inflammatory efficacy. Inflammation2000; 24:357-370.
7. Kim DH, Stark WJ, O’Brian TP, Dick JD. Aqueouspenetration and biological activity of moxifloxacin0.5 % ophthalmic solution and gatifloxacin 0.3 %solution in cataract surgery patients. Ophthalmology2005;112: 1992-1996.
8. Ke T-L, Graffe G, Spellman JM, Yanne JM. Nepafenac, aunique nonsteroidal prodrug with potential utility inthe treatment of trauma induced ocular inflammation.Inflammation 2000; 24:371-384.
9. Tom Wallers, Michael Raizman, Paul Ernest. In vivopharmacokinetics and in vitro pharmacodynamics ofnepafenac, amfenac, ketorolac and bromfenac. JCataract Refract Surg 2007;33:1539-1545.
10. Heaton J, Hiddeman JW, Hackett RB, et al. Oculareffects of Nepafenac ophthalmic suspension followingsix months of topical ocular administration topigmented rabbits. Paper presented at: The ARVOannual meeting ; May 03, 2005; Fort Lauderdale , FL.
11. Walker LM, Rice RL, Heaton JD, et al. Ocular effects ofNepafenac ophthalmic suspension following three
months of topical ocular suspension to cynomolgusmonkeys. Paper presented at: The ARVO annualmeeting; May 03, 2005; Fort Lauderdale, FL.
12. Heier JS, Topping TM, Bauman W et al. Ketorolac versus
predinisolone versus combination therapy in thetreatment of acute pseudophakic cystoid macularedema. Ophthalmology.2000;107:2034-2038.
13. Flach AJ. Discussion: ketorolac versus prednisoloneversus combination therapy in the treatment of acutepseudophakic cystoid macular edema. Ophthalmology2000;107:11:2039.
288 Kerala Journal of Ophthalmology Vol. XXI, No. 3
14. McColgin AZ, Raizman MB. Efficacy of topical Voltarenin reducing the incidence of postoperative cystoidmacular edema. Invest Ophthalmol Vis Sci.1999; 409(Suppl):S289.
15. O’Brien TP. Emerging guidelines for use of NSAIDtherapy to optimize cataract surgery patient care.Curr.Med REs Opin.2005;21:7:1131-1138.
16. Kapin MA, Yanni JM, Brady MT, et al. Inflammationmediated retinal edema in the rabbits is inhibited bytopical nepafenac. Inflammation.2003;27:5-281-291.
17. Gamache DA, Graff G, Brady MT, et al. Nepafenac, aunique nonsteroidal prodrug with potential utility inthe treatment of trauma–induced ocular inflammation:Inflamamtion.2000; 24:4:357-370.
September 2009 SR John et al. - Nepafenac 289
Recent Advances in The Back of
The Eye Drug DeliveryDr. Meena Chakrabarti MS DO DNB
treatment 1,5. Like solutions and particles implants can
also result in unequal drug distribution due to vitreous
heterogenicity and placement of implant peripheral to
retina to avoid disruption of the visual field. Implants
however come close to the zero-order kinetics: ie the
level of administered drug remains constant throughout
the delivery period.
Implants can be either biodegradable or non
biodegradable. Biodegradable implants do not require
surgical removal. Their disadvantages are a variability
in release kinetics due to differing rates of vitreous
turnover and a final burst in drug release profile. Non
biodegradable implants provide a more controlled drug
delivery but require a second surgical procedure for
removal.
Two ocular implants Vitrasert (Ganciclovir 4-5 mg Bausch
and Lomb, Rochester, NY) and the recently approved
Retisert (flucinolone acetonide 0.59 mg, Bausch and
Lomb) are commercially available. Vitrasert releases
ganciclovir for approximately 5-8 months while Retisert
releases flucinolone for up to 30 months and is currently
the only approved treatment for non-infectious uveitis
of the posterior segment 6.
Other implants that have been developed are
1. A novel doughnut shaped biodegradable implant 7
for delivery of ganciclovir and foscarnet. The
central hole assures easier suturing and the
implant does not need removal.
2. Biodegradable posudrex implant (Allergan, Irvine,
CA) for delivery of dexamethasone in treatment
Introduction
Once the active treatment agent that is efficacious in
the management of posterior segment diseases is
determined, the next big obstacle is the back of the eye
drug delivery. Topical eye drops are far superior to all
other routes of administration with respect to safety,
comfort, affordability and ease of use. However topical
medications are least effective in delivering therapeutic
concentrations of the drug to the retina 1. Hence the
majority of developmental efforts in retina therapeutics
is focussed on novel non-topical delivery systems.
Intravitreal injections introduced in 1945 2,3 provides
superior drug bioavailability in the posterior segment
compared to topical and systematically delivered
agents. However this method of drug administration
has several drawbacks which includes frequent
(monthly / bimonthly) outpatient visits, and carry the
risk of serious complications such as vitreous
hemorrhage, retinal detachment and endophthalmitis.
Intraocular implants 4 are designed to provide drug
release into the posterior segment for longer periods
of time (months or even years) compared to particles
or solutions. These implants are usually placed at the
level of the parsplana during a surgical procedure.
Compared to intravitreal injections, drugs released from
implants deliver more consistent levels of the drug,
avoids side effects associated with frequent intravitreal
injections, minimize peak concentrations and result in
smaller quantities of drug being required for
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
OCULAR
PHARMACOLOGY
290 Kerala Journal of Ophthalmology Vol. XXI, No. 3
of macular edema associated with retinal vein
occlusions.
3. Iluvien (Alimera, Alpharetta, GA) 8 a non
biodegradable implant to deliver flucinolone
acetonide in diabetic macular edema and designed
to sustain therapy for 24-36 months.
In the past few years researchers have developed
intraocular devices with fewer complications, and
relatively safe, sustained and effective localized
administration. These include
1. Particulate polymeric drug delivery systems
(Microparticles / Nanoparticles)
2. Phospholipid bilayer encapsulated drug delivery
system (liposomes)
3. Iontophoresis: where an electric current is used
to drive ionized drugs into tissues.
Microparticles, Nanoparticles and
Liposomes
The main problem that limits the effectiveness of
intravitreal injections is the lack of homogenicity of the
human vitreous caused by gradients. Injected drugs do
not therefore spread throughout the vitreous resulting
in a significant variability in the drug concentration at
the target site. Nano particles or micro particles are
new formations which can spread more uniformly
throughout the vitreous, increase the duration of action,
and decrease the peak concentration.
Injectable nano particles 9 (1nm to 1000 nm in
diameter) and microparticles (1 nm to 1000 nm in
diameter ) made of polymer encapsulated drug are
novel drug delivery systems that aim to increase the
drug penetration and also increase the duration of
action of small molecules.
Particulate system can be in the form of
1. Nanospheres and microspheres: which are
uniform polymer drug combinations in which the
drug is dispersed homogenously throughout a
polymer matrix.
2. Nanocapsules and Microcapsules: where the drug
is surrounded by a spherical polymer capsule and
released throughout its pores.
3. Polycion complex (PIC) micelles that can be laser
activated are in development and have
successfully inserted DNA into rat retinas through
a process called photochemical internalization in
which light induces the transfer of DNA directly
into cells 10.
4. Liposomes: with encapsulated drug can bind to a
cell membrane and facilitate drug transfer across
the membrane. They are less stable than particles
made of polymer. Both hydrophilic and
hydrophobic drugs can be encapsulated into
liposomes. Research have shown that they can
effectively carry genes to the rat retina following
injections.
Almost any drug can be encapsulated. This
method of drug delivery aids in (1) stabilizing the
active form of the drug (2) increases its half life
(3) increases drug absorption due to slower
elimination rate (4) decreases peak concentrations
reducing the risk of toxicity.
One of the major disadvantages of this mode of delivery
is that nanoparticles and microparticles are heavier than
vitreous. So when they are injected they tend to sink
to the bottom of the vitreous cavity. Particles size can
also have a profound effect on the drug bioavailability
after injection with larger particulate system tending
to maintain superior sustained drug release.
Nanotechnology may have an impact on the treatment
of retinal diseases through gene delivery, drug delivery,
cell delivery, retinal neural prosthetics and nano surgery.
Gene delivery has been attempted with viral vectors
but carry the risk of immunogenicity and mutagenesis.
Non viral vectors such as polymers and lipids also have
the ability to carry genes but with lower risk of
immunogenecity, lower cost and greater ease of
production than viral vectors. The electrostatic
interaction of cationic polymers with RNA or DNA
molecules carrying a negative charge results in
condensation and formation of the material into
particles in the nanoscale range. These polymer
nanoparticles can protect genes from enzymes and
mediate their entry into cells. Incani and colleagues 12
found that polyplexes ……………… complexes of
cationic polymer with plasmid DNA can have
transfection efficiencies comparable to adenoviral
September 2009 Meena Chakrabarti - Recent advances in the back of the eye drug delivery 291
vectors but with reduced safety risks. Colloidal nano
particles carrier systems have been tried for sustained
drug delivery for chronic diseases such as glaucoma
and macular degeneration. Nano particles are also
promising for targeted delivery of drugs to intra ocular
tumors. Sustained submacular delivery may be
enhanced by the use of biocompatible film that serves
as a carrier for drug loaded nanoparticle Fig1. For an
extra ocular approach arrays of hundreds of
microneedles that penetrate the sclera to deliver drugs
to the posterior segment have been designed using
microfabrication technology Fig. 2.
Polymer scaffold engineered on the nanoscale can
increase the survival and differentiation of cells for
retinal transplantation 13.
Use of nanoparticles in engineering of retinal prosthetics
is being investigated with the aim of rejenuvating , by
passing, or taking advantage of the residual retinal
function in patients with retinitis pigmentosa and other
inherited degenerative retinal diseases 14.
Iontophoresis and Suprachoroidal drug
administration
Iontophoresis is a method of drug delivery in which an
electrical current drives charged drug molecule through
either the cornea or sclera and into the retina and
vitreous. It offers a non invasive alternative to
intravitreal injections, particles or implants. The current
leader in clinical ocular iotophoresis is Eye Gate pharma
(Waltham, MA) which is currently investigating this
technology for drug delivery. It uses a reusable battery
powered generator and a disposable applicator.
The Eyegate II uses an inert electrode that can
accommodate both positive and negatively charged
drugs. The mechanism of action of the inert electrode
is electrorepulsion of the same charged molecule which
creates high velocity to achieve flux to the targeted
tissue.Fig. 3
The surface area is important in this technology due to
current density. By delivering the current to the sclera,
the surface area is maximized and current density is
lowered increasing the safety profiled of the device.
The Eyegate II 16,17,18 has shown efficacy in delivering
proteins, si RNA, corticosteroids and nanoparticles in
rabbit studies. Safety of this device on human sclera 19
was shown using a buffer solution. Phase 2 study of
EGP - 437, a corticosteroid delivered using this system
for the treatment of dry eye syndrome has been
completed. Phase II study in uveitis, glaucoma age
related macular degeneration etc is underway.
For patients with retinal tumors, iontophoresis is being
researched as a potential alternative to the use of
systemic chemotherapy. In a mouse model, investigators
found that iontophoresis could successfully transport
carboplatin, a cytotoxic compound for the treatment
of retinoblastoma.
The suprachoroidal drug delivery using a 300 mm
microcatheter 21 (i track -400 , i-science Interventional
corporation, Menlo park, CA ), introduced through a small
anterior incision at the parsplana has been shown to be able
to access the suprachoroidal space. The safety, efficacy and
pharmacokinetics with triamcinolone, a combination of
triamcinolone A and Avastin is being investigated.
(Fig. 5 & 6)
Transporter Targeted Drug delivery to the
retina:
This method of drug delivery targets nutrient
transporters on ocular barriers utilizing a prodrug
approach. Nutrient transporters are transmembrane
proteins involved in the transportation of essential
nutrients and xenobiotics across biological membranes,
thereby regulating the supply of essential ingredients
into the cell.
Several transporters for nutrients and endogenous
compounds are expressed on both the apical and
basolateral sides of the epithelial barriers of various
tissues such as intestine, kidney, BBB, BRB and placenta.
To take advantage of the nutrient transport system, the
parent drug must be covalently conjugated to the
nutrient moiety by an enzymatically cleavable bond
generating a prodrug. Prodrugs significantly enhance
absorption of poorly permeable parent drug. These
prodrugs are recognized by the membrane transporters
as substrates and are transported across the epithelial
or endothelial barriers. Subsequently the prodrugs are
enzymatically cleaved to release the parent drug and
the ligand which in most cases is a nutrient, non toxic
and easily eliminated. (Fig. 7)
Super selective intra arterial chemotherapy in
retinoblastoma aims to deliver a high concentration of
292 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Fig. 1. Biocompatible film for drug delivery 20 nm thickbiocompatible film with multiple drug loadednanoparticles for sustained drug delivery. [Adaptedfrom Retina Today May/ June 2009, Vol.4, No.4]
Fig. 2. Microneedle Array. The size of the experimentalmicroneedle array is shown by its placement on theresearcher’s finger. There are 400 needles in the array.[Adapted from Retina Today May June 2009 Vol.4,No.4]
Fig. 3. The Eye Gate II delivery system.
Fig. 4. The EyeGate II applicator is placed directly upon thesclera.
Fig. 5. The Ophthalmic microcathete for suprachoroidaldrug delivery.
Fig. 6. (a) & (b) View of the Microtheter beacon tip in suprachoroidal space
the drug to the trauma and achieve less exposure via a
low dose systemically to the patient. The goal is to
eliminate the need for enucleation and systemic
chemotherapy in children with RB. Under general
anaesthesia, the femoral artery is catheterized with a
microcatheter (450 nm) which is passed up into the
abdominal aorta, thoracic aorta, internal carotid arteries
and into the ophthalmic artery which measures below
550 nm to 1000 nm in diameter in children.
References
1. Hughes PM, Olejnik O, Chang-Lin JE, Wilson CG. Topicaland systemic drug delivery to the posterior segments.
Adv Drug Deliv Rev.2005;57(14):2010-2032.
September 2009 Meena Chakrabarti - Recent advances in the back of the eye drug delivery 293
2. Wu L, Martinez- Castellanos MA, Quiroz-Mercado- Het al. Twelve –month safety of intravitreal injections ofbevacizumab (Avastin): results of the Pan –AmericanCollaborative Retina Study Group (PACORES). GraefesArch Clin Exp Ophthalmol.2008;246 (1) 81-87.
3. Von Sallmann L. Penicillin therapy of infections of thevitreous. Arch Ophthalmol 1945; 33:455.
4. Bourges JL, Bloquel C, Thomas A et al. Intraocularimplants for extended drug delivery: therapeuticapplications. Adv Drug Deliv Rev. 2006; 58(11):1182-1202.
5. Del Amo EM, Urtti A. Current and future ophthalmicdrug delivery systems. A shift to the posterior segment.Drug Discov Today. 2008;13 (3-4):135-143.
6. Hsu J. Drug delivery methods fro posterior segmentdisease. Curr Opin Ophthalmol.2007; 18(3):235-239.
7. Choonara YE, Pillay V, Carmichael T, Danckwerts MP.Syudies on a novel doughnutshaped minitablet for intraocular drug delivery. AAPS Pharm Sci Tech. 2007;8(4):E118.
8. Alimera. Iluvien: addressing the Ophthalmic Crisis ofDiabetes.2008; v. 2009.
9. Csernus VJ, Szende B, Schally AV, Release of peptidesfrom sustained delivery systems (microcapsules andmicroparticles) in vivo. A histological andimmunohistochemical study. Int J Pept ProtienRes.1990; 35(6):557-565.
10. Tamaki Y. [Novel approach for management of age-related macular degeneration-antiangiogenic therapyand retinal regenerative therapy]. Nippon Ganka GakkaiZasshi. 2007;111(3):232-68; discussion 69.
11. Masuda I, Matsuo T, Yasuda T, Matsuo N. Gene transferwith liposomes to the intraocular tissues by differentroutes of administration. Invest Ophthalmol Vis Sci.1996; 37(9):1914-1920.
12. Incani V, Tunis E, Clements BA, Olson C, Kucharski C,Lavasanifar A, Uludag H. Palmitic acid substitution oncationic polymers for effective delivery of plasmid DNA
to bone marrow stromal cells. J Biomed Mater Res A.2007;81 (2):493-504.
13. Tao SL, Desai TA. Aligned arrays to biodegradable poly(-carprolactone) nanowires and nanofibers by template
sysnthesis. Nano lett.2007.;7 (6):1463-1468. doi:10.1021/nl0700346.
14. Caspi A, Dorn JD, McClure KH, Humayun Ms,Greenberg RJ, McMahon MJ. Feasibility study of aretinal prosthesis: spatial vision with a 16-electrodeimplant. Arch Ophthalmol.2009;127398-401
15. EyeGate. Pipeline [Internet]. Waltham, MA, 2009.
16. Blalock T, Gee R, Manzo M, Ruiz- Perez B, Rao R. Single–dose treatment with dexamehazone phosphateresolves concanavalin A – induced dry eye in rabbits.Poster presented at the annual meeting of theAssociation for Research in vision and Ophthalmologymeeting; April 27-May 1 2008; Fort Lauderadale, FL.
17. Ruiz – Perez B, Blalock T, Dowie T, et al. Transscleraldelivery of a 12.4k Da protein by ocular iontophoresis.Poster presented at the annual meeting of theAssociation for Research in Vision and Ophthalmologymeeting; April 27-May 1 2008: Fort Lauderdate, FL.
18. Patane M, Ji Guo, Schubert W, Landosca J. Iontophoreticdelivery of PRINT ® (Particle Replication In non-wetting templates) Nanoparticles using the Eyegate ®II device. Poster presented at the annual meeting of theControlled Release Society , July 12-16,2008; New York.
19. Reddy M, Thimmaiah R, Cohen A, et al. Clinicalexperience with the EyeGate II ® delivery system: safetyand tolerability in healthy male and female adultvolunteers. Poster presented at the annual meeting ofthe Association Research in Vision and Ophthalmologymeeting; April 27- May 1 2008; Fort Lauderdale, FL.
20. Hayden B, Jockovich ME, Murray TG, et al.Iontophoretic delivery of carboplatin in a murine modelof retinoblastoma. Invest Ophthalmol Vis Sci.2006;47(9):3717-3721.
21. Olsen TW, Feng X, Wabner K et al. Cannulation of thesuprachoroidal space: a novel drug deliverymethodology to the posterior segment. Am J.Ophthalmol.2006;142 (5):777-787.
22. Kansara V, Hao Y, Mitra AK. Dipeptide monoesterganciclovir prodrugs for transscleral drug delivery:targeting the oligopeptide transporter on rabbit retina.J Ocul Pharmacol Ther.2007; 23:321-334.
294 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Care and Maintenance of Contact Lens –
An OverviewDr. Pravin Tellakula MS
Care and maintenance is one of the most critical aspects
of contact lens wear. It can influence the success of
contact lens wear and patients’ satisfaction with their
lenses. Choice of lens care regimen depends on factors
such as lens type, lens material, replacement schedule
of lens, lifestyle and specific patient needs.
“The biggest risk factor in Contact Lens wear is the
person wearing them”
- Geoff Wilson
Safe and effective wear depends on synergism of a good
lens, a compliant patient and periodic professional
monitoring. It is imperative that the purposes and
importance of proper care and maintenance be
impressed upon the prospective contact lens wearer as
soon as contact lens wear is considered seriously.
Role of Care and Maintenance
The overall aims of care and maintenance are
� to prevent and minimise microbial contamination
� reduce deposits
� and attain and maintain ready-to-wear state of
lenses
The various products of care maintenance provide one
or more of the following functions: -
� Cleaning
� Disinfection
� Protein Removal
� Wetting / re-wetting
Regardless of the type of contact lens (except daily
disposables), an appropriate care system must be used.
A typical care system consists of the components listed
Components of Care and Maintenance
� Daily cleaner
� Rinsing solution
� Disinfecting solution/unit
� Weekly/protein cleaner
� Lubricating/rewetting solution
� Lens storage case
DAILY CLEANER - Function
Daily cleaners usually contain surfactants and are used
to remove most loosely bound foreign matter on the
lens surface, such as, Cell debris, Mucus, Lipids,
Proteins, Cosmetics, Micro-organisms, and inorganic
deposits.
The main functional component in a cleaner solution
is the surface-active agent(s) also known as
surfactant(s) (e.g. isopropyl alcohol, tyloxapol,
polyvinyl alcohol, poloxamer-407, amphoteric 10,
poloxamine, hexylene glycol, octylphenoxy ethanol,
tween 21). Surfactant molecules emulsify, dissolve
and/or disperse lipid globules, debris and other lens
contaminants. This is accomplished by the surfactant
forming a monomolecular layer over the contaminant
using the polar ends of its molecules to bind the layer
to the contaminant’s surface. The ‘coated’ contaminants
repel one another mutually or exhibit a lowered surface
tension1.Adithya Eye Clinic, Chennai
CURRENT
C0NCEPTS
September 2009 Pravin T. et al. - Contact Lens Care 295
The other main components are Non-ionic or ionic
chemical compounds, to reduce interaction
between the lens and the solution, and anti-microbial
agents, primarily used as preservatives.
The additional components in a cleaner include
Osmolality adjusting agents, a buffer system to
adjust the pH, Chelating agents for removing lens
contaminants and viscosity enhancing agents.
Viscosity-enhancing agents such as polyvinyl alcohol
or methylcellulose also facilitate cleaning.
Hypertonicity and abrasiveness are properties that
have been added to enhance the efficacy of some lens
cleaners. Hypertonicity results in extraction of water
from soft lenses, which may help remove some soluble
contaminants. Polymeric beads in some cleaners
have a mildly abrasive effect on protein and other
surface deposits. Apart from this Alcohol to remove
lipids and Enzymes to digest proteins are also added.
Rubbing also enhances the efficacy of the cleaning
solution’s surfactant properties.
Caution to be observed when using abrasive cleaners.
Excessive rubbing may cause scratches on the lens and
can also sometimes induce minus power 2, 3.
Rinsing Solution
Value of Rinsing- regardless of the type of
cleaner used it is important for the lens to be thoroughly
rinsed to remove the excess Daily Cleaner, Loosened
deposits and Micro-organisms. If the cleaner is allowed
to remain on the lens and placed in the enzymatic
cleaner, it may induce foaming resulting in the solution
bubbling out and leaving the lens in a dehydrated state4. It is also good to rinse lenses after overnight storage.
Buffering agents are included in rinsing solution
formulations so that their pH is approximate that of
tears. The pH of normal tears is, on average 7.2, but is
subject to individual variation. To enhance the
compatibility of solution and tear pHs at lens insertion,
the solution is normally buffered lightly.
Many different types of solutions can be used for rinsing,
such as, Unpreserved Saline, Preserved Saline and
Multi-purpose solutions. Use of buffered isotonic saline
is preferred to un-buffered as absorption of atmospheric
carbon dioxide lowers the pH.
Disinfecting Systems
Purpose of disinfection
Contact lenses may compromise the eye’s natural
defence by:
� Inhibiting tear film washing action
� Introducing more micro-organisms
� Compromising epithelial barrier function
Functions of the disinfecting solution are to kill or
deactivate potentially pathogenic organisms including:
Bacteria, fungi, viruses, amoebas and maintain lens
hydration
Antimicrobial activity can be divided into three levels
of efficacy (Anger and Currie, 1995) 5.
- Sterilization is the killing of all microbial life forms,
a situation impossible to achieve with normal lens care
products and procedures.
Fig: 1 Cleaning Procedure – Rub and Rinse
DAILY CLEANER – Procedure
1. Wash hands and dry them (avoid moisturizing/
perfumed soaps)
2. Place lens in the palm of the hand
3. Place 2-3 drops of cleaner on each lens surface
4. Rub with forefinger for about 15 seconds per side
using a ‘to & fro’ and ‘L-R’ action. Rolling the
forefinger in both directions cleans the lens
periphery
5. Rinse well
Cleaning should be done with all types of lens including
disposables.
The mechanical action of rubbing and rinsing
reduces significantly the amount of loose debris and
the number of microorganisms on a lens.
296 Kerala Journal of Ophthalmology Vol. XXI, No. 3
- Disinfection is a dynamic process, usually preceded
by a cleaning and rinsing step, intended to kill and/or
remove microbial and viral contaminants from contact
lenses.
- Preservation is the killing or inhibition of growth
of a select range of microorganisms to prevent product
spoilage during consumer use. The choice of
preservative is governed to a large extent by the
resistance of the microbial targets and the sensitivities
of the eye exposed to the preservative via contact lenses
or eye drops.
Disinfection Systems Types
The two main types of disinfection systems available
for soft contact lenses are heat and chemical.
1. Heat-based disinfection systems use heat in
the range from 70°C to 125°C to kill or deactivate
living lens contaminants (ideally 80-90 degrees for
10 minutes). The advantage is that it is very effective
and does not cause any allergy or discomfort.
However, heat can cause problems for the patient due
to alterations that occur within the lens following
long-term use. Heat disinfection systems generally
decrease lens life span and eventually cause lens
discolouration. The Optical and physical properties of
the lens can sometimes be altered due to excessive
heating and can result in denaturation of protein in
and on the lens RGP lenses will warp when heated and
hence cannot be used. Recently, a system for thermal
disinfection of contact lenses in a domestic microwave
oven has been released.
2. Chemical disinfection systems vary greatly and
a wide variety of types exist. Included in the chemical
systems category are the current hydrogen peroxide
and multi-purpose solutions. Chemical disinfection can
be subdivided into oxidative (hydrogen peroxide and
chlorine) and conventional cold chemical.
Conventional Cold Chemical Disinfectant-
Based Solutions
The characteristics of the disinfectants should be
such that they are compatible with other ingredients,
non-toxic and non-irritating, stable over time and
effective against a wide range of organisms.
Disinfectants such as thimerosal, chlorhexidine,
benzalkonium chloride and sorbic acid should be used
with caution because of their potential for disinfectant-
induced sensitivity reactions. The various chemicals
used as disinfectants are listed below.
Thimerosal, a mercurial antibacterial, is effective as
an antifungal agent. It has been used extensively in
the past in solutions for both rigid and soft CLs. It is
most effective neutral or slightly alkaline pHs. It acts
by bonding with cell enzymes, inhibiting their activity
and killing the organism. Its concentration in the
solution varies from 0.001 % - 0.2 %. However, it is
reported to have reduced activity in combination with
ethylenediamine tetracetic acid (EDTA or sodium
edetate) and is incompatible with BAK. Thiomerosal
can be decomposed by light. Cytotoxic reactions of the
corneal epithelium have been reported 6.
Chlorbutanol is a chlorinated alcohol preservative
with broad spectrum of action. It is however, slow acting
against and bacteria and has a distinctive odour.
Originally used on PMMA lenses, it is now not a
common ingredient. It is effective in acidic pH and used
along with other preservatives. This unstable and
volatile preservative is used in a concentration of
0.5 %.
Benzyl Alcohol is a disinfectant and preservative for
RGP and PMMA lenses. It is unsuitable for use with
soft contact lenses. It is non-cytogenic and relatively
non-sensitizing. It is a bactericidal and viricidal but
ineffective against Pseudomonas aeruginosa in low
concentrations. Like other alcohols (isopropyl alcohol,
isopropanol, ethanol), it behaves like a lipid solvent.
Chlorhexidine gluconate (CHG - a biguanide
antimicrobial) is used both in hard and soft contact
Fig. 2. Solution induced corneal toxicity
September 2009 Pravin T. et al. - Contact Lens Care 297
lens solutions. Chlorhexidine inhibits cation transport
and membrane bound ATP in cell membranes. It can
bind on protein deposits on lenses and can cause
irritation. Not compatible with Thimerosal. It is known
to adsorb until saturation and leach from the lens
causing toxic reactions on the cornea.
Benzalkonium chloride (BAK) is a quaternary
ammonium compound and used mainly for PMMA lenses.
It works by adsorbing to cell’s membrane, thereby
increasing its permeability and leading to rupture of
the cell. For this reason corneal exposure to the solution
should be avoided. The concentration of BAK in solution
is 0.001 – 0.01% and is effective at an alkaline pH of 8.
BAK decomposes in light. Long-term use of this preservative
may cause the lens surface to become hydrophobic.
EDTA, Edetate, Disodium edentate, Edetic acid
are not strictly preservatives. They are variously
described as preservative enhancers, preservative
potentiators and chelating agents. EDTA is contained
in most CL solutions. EDTA potentiates the action of
quaternary ammonium compounds against gram-
negative organisms but not gram-positive ones.
EDTA’s action removes, by chelation, divalent cations
such as calcium and magnesium ions from solutions
and/or cell walls of gram-negative organisms. Such cell
wall disruptions slow or prevent cell growth. EDTA does
not bind to lens materials significantly and is normally
used in combination with other preservatives. It has a
synergistic action with BAK, which enhances the
effectiveness of the blended solution.
Sorbic acid has antibacterial and limited antifungal
activity. Its concentration in SCLs has not been shown
to cause death of the corneal epithelial cells but
adherence to contact lenses is facilitated by its organic
reaction with the amino acid (lysine) in tear proteins,
and causes a yellow or brown discolouration.
DYMED : Poly aminopropyl biguanide (PAPB),
Poly hexamethlene biguanide (PHMB) are new
generation of preservatives developed to address the
problems previous preservatives created, like ocular
irritation and hypersensitivity. Dymed is the marketing
name for PAPB. Initially used in anti-malarial water
treatment and swimming pool chemical has now found
a place as an adjuvant in the treatment of
Acanthamoebakeratitis 7.
PAPB selectively binds with negatively charged
phospholipids of the cell walls causing membrane
damage, cell content leakage and ultimately cell death.
It is used in a low concentration of 0.00005 – 0.0005 %.
Polyquad is the marketing name for a high molecular
weight (polymeric) quaternary ammonium compound:
Poly(quaternium-1), polidromium chloride,
onamer M
This type of preservative is used in both rigid and soft
lenses in concentrations of 0.001 – 0.005 %. Its high
molecular weight of 5000 restricts its entry into lens
materials thus minimizing ocular reactions.
Chlorine Systems : The use of chlorine-releasing
tablets in SCL disinfection systems dates back to the
1970s. The recent systems are supplied as convenient
blister packed anhydrous effervescent tablets of either
stabilized halane or halazone benzoic acid. Both tablets
slightly differ in the amount of available chlorine
(4 – 8 ppm). The tablet is dissolved in 10ml of unpreserved
saline to make a disinfecting solution of pH between
5.5 and 7.5.4 hours exposure is recommended. The
antimicrobial activity will depend on the concentration
of undissociated hypochlorous acid. Lenses should be
thoroughly rinsed before re-insertion.
The dissociated hypochlorous acid produces
hypochlorite and chlorine, which are also bleaching
agents. Lenses tinted with reactive dyes can have their
colour altered.
Hydrogen Peroxide based chemical disinfectant
solutions may be either preserved or preservative free
and can be divided into two main types:
� One-step system
� Two-step systems
Hydrogen peroxide systems are normally formulated
Fig. 3. Thiomerosal Toxicity of skin
298 Kerala Journal of Ophthalmology Vol. XXI, No. 3
with a 3 % peroxide concentration whose pH is often
acidic at 3.0 – 4.0 8. For a lens to be wearable following
disinfection, neutralization is required. For the purpose
of neutralization substances like sodium pyruvate,
sodium thiosulphite, catalase and sodium bicarbonate
have been used. Most systems decompose hydrogen
peroxide into saline and oxygen catalytically.
Disinfection in hydrogen peroxide is reasonably
effective in 15-20 minutes.
One-step systems are formulated so that the
peroxide disinfection and neutralization are performed
during the recommended time. With tablet-using
systems a delay is applied to the neutralization phase.
With disc-based systems, no delay is applied to the
neutralization phase. Regardless of which of these
systems is used special vented lens cases are required
to allow the oxygen generated to escape. One-step
systems use either a catalytic (platinum) disc (6 hours)
or a time-delayed catalase tablet (2 hours).
When neutralization is performed as a separate step,
the system is called a two-step system. Very early
systems ‘neutralized’ peroxide using pre-measured
quantities of sodium bicarbonate for a minimum of
10 minutes. In fact, the process was not true
neutralization and usually took longer than 10 minutes.
Rather, the bicarbonate altered the solution pH
(upwards) to levels at which peroxide was inherently
less stable. The peroxide solution then began to
decompose slowly into water and oxygen.
With two-step systems it is recommended that lenses
are stored overnight in the peroxide and neutralized
immediately before lens usage.
Advantages of the hydrogen peroxidase system is
that they are rapid killing large numbers of most
organisms in a short time period, 10-20 minute
soaking time. High anti microbial efficacy and
non-toxic decomposition products are its other
advantages.
Disadvantages being that once it is neutralized, a
peroxide system has no antimicrobial power and can
sometimes cause irritation in the eye if not neutralized
properly. It is not perfectly compatible especially with
high water content, ionic contact lenses in that it can
reversibly alter lens parameters and water content.
Multi-step peroxidase systems can be overly complex
and confuse the patient.
Multi- Purpose Solution
Many modern lens care systems use one solution to
perform the functions of a number of components,
thereby reducing the actual number of solutions
required.
For ease of use and patient convenience, multi-purpose
solutions (one-bottle systems) are formulated to allowFig. 4. Hydrogen peroxide System
Table: Summary of recommended Disinfecting Systems based on Lens Material1
HEAT COLD CHEMICAL PEROXIDE MULTI-PURPOSE
SCLLow Non-ionic Yes Yes Yes Yes
X Yes X YesLow Ionic Some Yes Yes Yes
High Non-ionic X Yes X YesHigh Ionic X Yes Yes Yes
UncommonPMMARGP X Yes Special Yes
Uncommon Formulation
For coloured contact lenses heat or hydrogen peroxide should not be used as it cause bleaching/ fading of the colour.
September 2009 Pravin T. et al. - Contact Lens Care 299
cleaning, rinsing and disinfection functions to be
combined. More recently even protein removers have
been added to these solutions.
Protein Remover
Protein removers, also known erroneously as enzymatic
cleaners, are included in the care systems for soft
Cleaving
Enzyme tablets act as protein removers by cleaving the
peptide bonds in tear proteins deposited on contact
lens surfaces 1. Since the action of the enzyme tablet
only loosens the protein, it is important to instruct the
patient to clean the lenses by rubbing and rinsing upon
completion of the deproteinizing process.
Rewetting Drops and Lubricants
Lens Lubricants permit lubrication and rewetting of the
lens while on the eye. Typically, they contain a low
concentration of a non-ionic surfactant to promote
cleaning, a polymer to lubricate the lens, buffering
agents and preservatives 10. Lens lubricants are
particularly helpful for wearers of extended wear lenses,
but can also be used with daily wear lenses. The drying
out of the lens on the eye from exposure to wind, low
humidity, and high temperatures may be relieved by
these products. Patients who experience difficulty
removing hydrogel lenses because of dehydration or
who frequently damage their lenses on removal may
also benefit from the use of lubricants. Lubricating and
re-wetting drops are formulated with viscosity-
enhancing agents (commonly polyvinyl alcohol,
methylcellulose, etc.).
Lens Storage and Cases
A poorly maintained contact lens case can be a source
of heavy contamination of contact lenses with
microorganisms. Biofilm or glycocalyx formation on the
surface of contact lens storage cases can harbour
Pseudomonas aeruginosa and Serratia marcereens 11.
The biofilm is produced by the bacteria themselves.
It protects the host bacterial cells from chemical or
preservative attack and traps nutrient particles and
Fig:5 protein deposits source:IACLE
Fig: 7 Dirty lens case
Fig: 6 Calcium deposits
contact lenses, and some RGP lenses, that are not
replaced regularly (>1 month). Not all protein
removers are enzyme-based.
Those that are, are usually supplied in tablet form.
Chemical-based systems are usually supplied as ready-
to-use liquids. These cleaners are effective in loosening
tightly bound protein deposits.
However, they cannot be expected to remove all
proteins.
Prior to protein removal, the lenses should be cleaned
and rinsed before being placed in the recommended
container with the tablet or solution for the
recommended time. Enzyme cleaners are ineffective
in the presence of lipid deposits or other debris. Protein
treatment is usually done weekly or at a frequency
dependent on the rate of patient protein deposition.
Heavy protein depositors, especially ionic high water
material lens wearers, may require an increased
frequency. Frequent use of protein removers are
required if heat is used as a disinfectant.
Lenses should be soaked in the remover for 15 minutes
to two hours, depending on the type of protein
remover used and rate of protein build-up.
Enzymes used include papain, pancreatin,
subtilisin, pronase, amylase, lipase, and
hydroxyalkylphosphonate. It is to be noted that
Papain is not compatible with hydrogen peroxide 9.
300 Kerala Journal of Ophthalmology Vol. XXI, No. 3
organisms. To avoid contamination, the lens case should
be rinsed after use and the lenses should be stored in
fresh solution.
CIBA vision has come out with a unique Pro Guard
lens case, infused with an anti-microbial agent that
helps prevent contamination. The contact lens case
contains silver atoms that have been electrically charged
(ions), and help reduce the possibility of contamination
by up to 40%.
Care of Lens Cases
Discard all the used solution from the case. This
prevents loss of disinfecting efficacy when fresh solution
is mixed with used solutions.
Scrub with a toothbrush and detergent weekly. Oil free
soaps or detergents are recommended for this step.
Rinse with hot water and rub thoroughly with a clean,
dry tissue.
Air dry. Keeping the lens case dry will prevent
colonization by microorganisms such as protozoa that
thrive in moist or wet environments.
It is also recommended that the lens case be replaced
at frequent intervals.
Lens Replacement Schedule and Care
Regimen
Daily Disposables
Because of its single use concept, this lens does not
require use of surfactant cleaner, disinfecting solution
or weekly enzyme. If needed, the patient can use
in-eye re-wetting drops or sterile saline for rinsing prior
to insertion.
Regular Disposables
These lenses are replaced weekly or bi-weekly. Suitable
care includes multi-purpose solutions given as complete
care system. If preferred, lenses can be rinsed with
saline prior to insertion or a lubrication solution used
to re-wet the lenses. No weekly protein removal is needed.
If a multi-purpose solution causes irritation or
discomfort, a surfactant cleaner can be used along with
hydrogen peroxide as disinfectant.
Frequently Replaced Lenses
Clean lenses with a multi-purpose solution or a
surfactant cleaner. Rinse with multi-purpose solution
or a saline solution (unit-dose, aerosol or preserved).
Disinfection may be done with heat, cold chemical,
oxidative or multipurpose systems. The final choice
depends on lens material and patient compliance.
Protein removal is required for 3 and 6 monthly-
replaced lenses but with lower frequency compared to
conventional lenses. It can be avoided in the case of
monthly disposables. Lubricating/re-wetting drops may
be used if required.
Conventional Lenses
Clean lenses with a multi-purpose solution or a
surfactant cleaner. Rinse with multi-purpose solution
or a saline solution (unit-dose, aerosol or preserved).
Disinfection may be done with heat, cold chemical,
Conventional Frequent Replacement Disposable> 6 months 1 month ≤ 3 months ≤ 1 month
Surfactant Cleaner Yes Maybe No
All Purpose Yes Yes Yes
Peroxide· One Step Yes Yes Yes· Two Step Yes No No
Enzyme Yes Maybe No
Clean Lens Cases weekly Yes Yes Yes
September 2009 Pravin T. et al. - Contact Lens Care 301
oxidative or multipurpose systems. The final choice
depends on lens material and patient compliance.
Protein removal is done weekly. It is performed using a
tablet or liquid form of protein remover which may be
chemical or enzymatic in nature. Some wearers may
benefit from wetting drops especially if they are working
in air-conditioned environment.
For regular wearers of conventional lenses heat or
thimerosal/chlorhexidine-based disinfection is not
recommended.
In-office Maintenance Of Diagnostic (Trial Set)
Lenses
SCL: Use heat if possible, otherwise peroxide
RGP: Use peroxide or store lenses dry
Re-disinfect non-disposable inventory trial lenses at
least once a month.
Multi-purpose solutions should only be applied to trial
lenses used very frequently and are not suitable for
long term storage. Regardless of the storage method,
all trial lenses should be cleaned and rinsed thoroughly
before storage.
In-office Procedures to Clean and Disinfect
Lenses
Various in-office procedures can be used to clean and
disinfect lenses.
Heater/stirrer units with/without:
-special-purpose care products
-oxidizing agents (hydrogen peroxide, sodium
perborate, sodium percarbonate, sodium hypochlorite,
etc.)
-special saline (e.g. saline with a calcium chelating
agent).
Oxidizing agents (e.g. 6 or 9 % hydrogen peroxide
with or without heat).
Standing waves. A lens cleaning system involving
low-frequency agitation of a lens vial containing contact
lenses and a cleaning solution is said to create
turbulence, which in turn dislodges surface
contaminants.
Ultrasound. Ultrasonic (using high frequency audible
waves between 15 and 20 kHz) agitation causes
removal of particulate matter from contact lens surfaces
by cavitation (intense agitation of small bubbles at the
lens surface). Is effective on low water content soft
lenses. If used for longer duration lens can become
opaque.
Ultraviolet. A lens disinfection system using either
direct UV irradiation of microbes or the production of
ozone by a UV-emitting (253.7nm) discharge tube 13.
The ozone is the actual disinfectant. It kills
microorganisms by breaking bonds and cross-links
between nucleic acids. It effectively disinfects SCLs and
RGPs.
Microwaves. This is an alternative form of heat
disinfection 12, albeit high heat. Microwave oven of
2.5GHz, 500 watts and turntable is used. While
undoubtedly effective against microorganisms, the
temperatures involved may also have deleterious effects
on the lenses and decrease their life expectancy. Vented
containers must be used and the lenses should be
re-hydrated in saline after irradiation.
Some systemic medications can cause lens damage and
ocular signs and symptoms, which have to be
differentiated from those of the care products. Some
care products may also not be compatible with certain
systemic medication.
Table: Possible Systemic Medication Interaction with
Soft contact lenses 14.
Clinical Findings
Medication
Lens Discolouration (yellow to orange)
NtrofurantoinPhenazopyridine
Phenophthalein
Rifampin
Rifadin
Sulfasalazine
Tetracycline
Corneal Staining
Tetracycline when used with Thiomerosal
Preserved products
Contact lens-related epithelial irritation
302 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Acetylsalicylic acid (aspirin)
Decreased lens wetting comfort
Antihypertensives
Tricyclic antidepressants
Antihistamines
Belladonnas
Anticholinergics
Current trends in solution and lens care
The trend in contact lens care is toward simpler, less
toxic systems that rely on patient compliance to function
optimally.
Simplified soft Lens Regimens
The common approach to soft contact lens care is to
use a one-bottle system. The leading, simplified
soft lens care products, ReNu (Bausch and Lomb),
SOLO-care (CIBA), Complete (Allergan), Opti-free and
Opti-one (Alcon) are very similar in their low toxicity
and reliance on digital cleaning and rinsing with clean
hands, followed by soaking in a clean case. While these
products have helped reduce toxic and allergic reactions
by using low toxicity preservatives and avoiding
thimerosal, chlorhexidine and exposure to hydrogen
peroxide, there is little evidence that they have led to
better compliance. Fortunately, frequent lens
replacement and the eye’s defence mechanisms have
kept most patients safe most of the time.
Sicca-like syndrome has been sometimes associated
with one-bottle lens care systems that contain
surfactants. These patients need a saline rinse (sorbic
acid preserved or sterile non-preserved) prior to lens
insertion. If stronger measures are needed, switching
to a hydrogen peroxide system can sometimes
dramatically improve comfort.
Hydrogen Peroxide and other Regimens
The more difficult to use and more expensive hydrogen
peroxide systems are often used only as problem-solvers
and have lost market share in the last decade. AOSEPT
one step is quick and ideal product for in-office
disinfection before re-inserting for a patient. Liquid
protein remover Unizyme, a product from CIBA
Vision for use with peroxide products, is said to work
in 10 minutes. For in-office trial lens storage, however
there is no substitute for heat disinfection.
RGP Lens Care
RGP solutions for the most part are not new, but if one
switches from cleaning/disinfecting/wetting/
conditioning/cushioning solution to cleaning/
disinfecting/ conditioning/but not wetting/cushioning
solution it should be made sure that wetting/cushioning
solution is added to the regime. Most of the currently
available products for RGP equally work well.
Allergy Sufferers
For allergic patients pre- and post lens wear use of
topical anti-histaminics or mast cell stabilizers or non-
steroidal anti-inflammatory agents will maximize
comfort.
To summarise while selecting a care regimen the
practitioner needs to consider the wearing schedule of
the patient, the lens type, replacement schedule and
convenience of the patient and ocular sensitivity issues
as well.
It is a good practice to repeat instructions and assess
demonstration by patient. Patients should be instructed
not to mix solution types and brands and to consult
the practitioner before substituting solutions.
The message for care and maintenance can be stressed
with the acronym
CRADLE – Clean, Rinse And Disinfect Lenses
Everytime
References
1. Sylvie Sulaiman, IACLE Contact Lens Course, Module
5: Units 5.1, pg 9, 1998
2. Carell BA et al: The effect of rigid gas permeable lenscleaners on lens parameter stability. J Am Optom Assoc63:193, 1992
3. Bennett ES, Henry VA: PGP lens power change withabrasive cleaner use. Int Contact Lens Clin 17:152, 1990
4. Mandell RB: Lens Handling, care and storage. In ContactLens Practice 4th ed, pp 568-597, 1988
5. Anger, C. B., and J. P. Curie. 1995. Preservation anddisinfection, p. II-187–II-213. In Contact lenses: theCLAO guide to basic science and clinical practice, vol.
September 2009 Pravin T. et al. - Contact Lens Care 303
II. Soft and rigid contact lenses. Kendall-Hunt, Dubuque,Iowa.
6. Tripathi BJ, Tripathi RC, Kolli SP: Cytotoxicity ofophthalmic preservatives on human corneal epithelium.Lens Eye Toxic Res. 9(3&4): 361-375, 1993
7. Larkin DFP et al: Treatment of Acanthamoeba Keratitiswith Polyhexamethylene biguanide. Opthalmology. 99:185-191, 1992
8. Rogan M: Systems for hydrogen peroxide disinfectionof soft contact lenses. Transactions of the British ContactLens Association, Annual Clinical Conference, May1985, Blackpool, England pp 40-42
9. Campbell R, Caroline P: A strong case for enzymaticlens care compliance. Contact Lens Spectrum 11:56,1994
10. Lowther GE et al: The Pharmacist’s Guide to ContactLenses and Lens Care. Atlanta, CIBA Vision corporation,1988
11. Feldman GL et al: Control of Bacterial Biofilms onRigid Gas Permeable Lenses. CL Spectrum 7(10): 36-39, 1992
12. Harris MG et al: In-office microwave disinfection of softContact Lenses. Optometry Vision Sci. 67(2): 129-132,1990
13. Harris MG et al: Ultra Violet disinfection of ContactLenses. Optometry Vision Sci. 70(10): 839-842, 1993
14. Shovlin J: Systemic Medications and their interactionwith soft contact lenses. Int Contact lens Clin 17: 250,1990
15. Edward S. Bennett and Barry A. Weissman, ClinicalContact Lens Practice text book, Chapters 25, 34 and35
16. IACLE Contact Lens Course, Module 5: 1998
17. Michael A. Ward, The Microbiology of Contact lensWear, Contact Lens Spectrum Journal, Sept. 1997:23-29.
304 Kerala Journal of Ophthalmology Vol. XXI, No. 3
A case report of colobomatous RDDr. Arya A.R MS, Dr. Biju John MS DNB FRCS
A 33 yr old housewife with no history of any systemic
illness presented with sudden onset of defective vision
in left eye 2 weeks back.There is no history of any
significant ocular illness in the past.No history of prior
trauma/seeing flashes/floaters prior to this episode.
Ocular examination revealed a visual acuity of 6/6 in
right eye and perception of light with accurate
projection in left eye.Anterior segment examination of
left eye revealed typical iris coloboma. (Fig. 1) and
microcornea (10 x 9mm)
Regional institute of Ophthalmology,Trivandrum.
Fundus examination revealed colobomatous area in the
inferior quadrant involving the disc along with retinal
detachment. (Fig. 2). No breaks were detected in the
peripheral retina even after careful indirect
ophthalmoscopy and slit lamp biomicroscopy with
3 mirror. It was presumend that location of the
break/breaks was within the colobomatous area.
Blood investigations were with in normal limits
A diagnosis of iris coloboma (typical) with
retinochoroidal coloboma and rhegmatogenous retinal
detachment in left eye was made.
Fig. 1. showing microcornea and iris coloboma in left eyeand normal appearance in right eye.
Fig. 2. showing retinochoroidal coloboma with RD in left eye.
Fundus
Fig: 3,4,5 Arrow showing laser mark.
Management - The patient underwent pars plana
vitrectomy. During removal of vitreous adjacent to the
colobomatous area “schlieren phenomenon” was
observed and this confirmed that the break was within
the coloboma. Internal drainage of subretinal fluid
along with simultaneous fluid air exchange was done
with the help of a silicone tipped cannula positioned
adjacent to the site of the presumed break.Retina
flattened and following this air silicone oil exchange
was done. Subsequently 3 rows of barrage laser burns
were placed all around the coloboma using LIO.
(LE) (RE)
CASE
REPORT
September 2009 Arya AR et al. - Colobomatous RD 305
Post operatively the retina remained attached and vision
was 1/60.She was discharged on the 4th day. Vision
improved to 3/60 by the 2nd post operative month and
the retina remained attached with barrage laser burns
in place.
Discussion
The term “coloboma”was introduced by Walther-
indicates a condition wherein a portion of a structure
of the eye is lacking.It occurs as result of inadequate
closure of embryonic fissure 5-7 wks postconceptional.
Childhood colobomas are important cause of childhood
blindness and visual impairment.
The development of retina lags behind in the region of
embryonic cleft. Initially the inner layer (presumptive
retina) normally grows more quickly than outer
pigmentary layer of optic cup. Normally the lips of
embryonic cleft meet in central part first and then
extends proximally and distally. Proximally the cleft
never closes where hyaloid artery enters and in this
region the eversion of inner layer is present for
sometime so that fusion of 2 outer layers is delayed
and a short nonpigmented strip remains at proximal
end of fissure. It is an accentuation of this process which
cause the formation of coloboma.Then the process of
atrophy and regression affects the retina throughout
the colobomatous area so that the layers disappear and
tend to be replaced by glial and fibrous elements. At
the same time sclera the development of which is largely
dependent on influence of optic cup remains thin &
poorly developed in abnormal region and tend to suffer
ectatic change.
If the process involves whole length of the fissure it
results in complete coloboma. If isolated areas of cleft
succeed in fusing it results in bridge coloboma.
Colobomas are usually inferonasal(typical). It can be
unilateral/bilateral. Even large coloboma which donot
involve the fovea may exhibit relatively preserved visual
acuity. Severe coloboma may be associated with
microphthalmos.
Ocular complications can be
-amblyopia
-refractive error
- choroidal neovascularisation
-retinal detachment.
CHARGE Syndrome-when coloboma is associated with-
Heart defects and other abnormalities such as
-Atresia(coanal)
-Retardation of Growth
-Ear abnormality
D/D
-Trauma
-Chorioretinal scar
Staphyloma-idiopathic
-myopic
associated with connective tissue disorder
-North Carolina macular dystrophy.
OCT can provide insight into the pathology at the
margin of coloboma. Coupled with the knowledge from
histopathological information can guide the
management of RDs secondary to coloboma of choroid
with a high degree of success.
Retinal detachments associated with coloboma of the
choroid present a surgical challenge. Within the
colobomatous area the retinal tissue is thin and
hypoplastic, the choroid and retinal pigment epithelium
(RPE) are not developed and the underlying sclera is
thin and ectatic, producing a staphyloma. The breaks
which are invariably within this area will be difficult to
locate due to the lack of contrast and are often located
correctly during vitrectomy as in our case.
Complete vitrectomy with method to create chorioretinal
adhesion around the coloboma and silicone oil or gas
tamponade provide effective treatment for
colobomatous retinal detachments.
References
1. Stephen J.Ryan-Retina 4th edition
2. System of ophthalmology-Normal andabnormal
development Vol 3.Sir Stewart Duke Elder.
3. Retina &Vitreous2008-2009; AAO.
4. Parsons Diseases of the eye. 20th edition.
5. Jalali S, Das T. Selection of surgical technique for retinal
detachment with coloboma of the choroid. Indian JOphthalmol 1994;42:27-30
306 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Vasoproliferative Tumour of The Retina-
A Case ReportDr Tufela Shafi MS, Dr Natasha Radhakrishnan MS DNB MRCophth, Dr Gopal S Pillai MD DNB FRCS,
Dr Roshan George MS
Retinal tumors are a rarity with peripheral retinal
tumors being still more rare. Here we report a case
where a peripheral retinal tumor presented with a
progressive decrease in vision over a long time due to
cystoid macular edema.
A 37 yr old male presented with history of gradual
painless progressive loss of vision left eye since 2 years,
with no improvement with treatment. On examination,
he had a best corrected visual acuity of 6/6 in the right
eye and 6/18 in left eye. Intraocular pressure in both
eyes was normal. Examination of the right eye including
anterior and posterior segments was within normal
limits. Anterior segment examination of the left eye
revealed 1+ cells and haze in the anterior chamber.
Vitreous showed 3+ cells and 2+ haze with membranes
and strands signifying partial PVD. Fundus examination
revealed hyperemic disc and stereoscopic examination
of the macula revealed the presence of cystoid macular
edema. There was fibrous proliferation and epiretinal
membrane along the arcades. A yellowish pink elevated
mass about 7 to 8 DD in size, with irregular surface
was seen superotemporally beyond the equator. Vessels
traversing and supplying the mass appeared dilated and
mildly tortuous and there were retinal pigment
epithelial changes at the base of the mass all around.
There were some telangiectatic vessels over the mass
along with hemorrhage. The lesion was also associated
with some intraretinal and subretinal exudation
(Fig 1).
Fluorescein angiography showed patchy
hyperfluorescence of lesion with multiple areas of
window defects corresponding to the RPE changes and
staining and blocked fluorescence secondary to the
exudation and mass lesion. The hyperfluorescence
increased in the late phase due to leakage in some areas.
There were areas of blocked fluorescence over the lesion
corresponding to areas of hemorrhage and in the
periphery of the lesion secondary to the RPE
hyperplasia. There was late disc leakage and flower
petal leakage at fovea signifying cystoid macular edema
(Fig 2).
OCT showed macular edema with a cystoid pattern with
a central macular thickness of about 450 microns.
B Scan showed an elevated, acoustically solid mass
about 9.7 x 7.1 x 3.2 mm in size and multiple echoes
in the vitreous suggestive of opacities (Fig 3).
The following differential diagnosis were entertained
1 Vasoproliferative tumour
2 An inflammatory or infective mass
3 Angioma of Von Hippel Lindau disease
4 Coats disease
A complete systemic evaluation was sought to rule out
coexistent systemic infections. Mantoux test was found
to be negative after 48 hours. Peripheral smear showed
normocytic normochromic blood picture. USG abdomen,
CT Thorax and MRI brain (plain and contrast) wereAIMS, Edapally, Kochi
CASE
REPORT
September 2009 T. Shafi et al. - Vasoproliferative retinal tumours 307
normal. Therefore infective or inflammatory mass was
ruled out. However, cholesterol levels were found to
be high (496.4mg/dl).
During the differential diagnosis, Von Hippel-Lindau
was excluded because of absence of grossly tortuous
and engorged blood vessels, absence of family history
for the disease and absence of other features of Von
Hippel-Lindau disease. In VHL even small tumours are
associated with grossly engorged and tortuous blood
vessels. Also the angiographic characteristics of Von
Hippel-Lindau like rapid filling of arteries and rapid
AV transit were not seen.
Coats disease was excluded because that is usually seen
in boys at a younger age, and usually does not cause
tumour like lesions even when exudation is severe. The
exudations in Coats disease are often flat and not
elevated. Besides tumour like lesions, if present in Coats
are accompanied by advanced exudative retinal
detachment.
Our patient showed the typical clinical picture of
vasoproliferative tumour. He had a solitary,
unilateral, yellowish vascularized tumour associated
with intraretinal exudation, RPE hyperplasia at the base,
telengiectasias and hemorrhage over lesion. He had
additional findings of anterior chamber cells, vitreous
cells and cystoid macular edema all of which have been
reported in various literature 1,2,3. We believe these
changes to be a secondary reactionary process to the
presence of tumour in the eye. FFA picture further
helped to confirm the diagnosis. Presence of elevated
levels of cholesterol in patients with vasoproliferative
tumour has been reported in literature 4.
With the diagnosis of vasoproliferative tumour, decision
to treat with multiple sessions of cryotherapy was taken
and patient given first session of cryotherapy. He is at
present on follow up.
Discussion
The term vasoproliferative tumour was coined by
Shields et al in 1995. Previously these tumours were
called presumed acquired haemangiomas, angioma like
lesions and peripheral retinal telengiectasia.
Vasoproliferative tumours of the retina are benign
vascular tumours of unknown origin. These tumours
generally present as yellow pink, one or more retinal
nodules seen usually in the pre-equatorial fundus,
generally in the inferotemporal quadrant but may also
be seen in the upper retinal quadrants 2,5 or even at
posterior pole 6,7. Their feeding and draining vessels
are slightly dilated but not enlarged or convoluted.
These tumours can be associated with additional clinical
changes like intraretinal and subretinal hemorrhages,
intraretinal and subretinal exudation, exudative retinal
detachments, hyperpigmentation of RPE, vitreous and
anterior chamber cells, vitreous hemorrhage, preretinal
macular fibrosis and macular edema 1,2,7. Exudation in
vasoproliferative tumours tends to creep back towards
the fovea and is hence seen in continuity with the
lesion4,7 . However preretinal gliosis can occur remote
from the lesion 7.
The pathogenesis of these tumours has not
been established. In a study of 103 patients, Shields
et al found that these lesions were idiopathic or
primary in 74 % and secondary to congenital,
inflammatory, vascular, traumatic, dystrophic and
degenerative ocular diseases in the rest 1. Primary
vasoproliferative tumours are solitary, unilateral
and generally located in the inferotemporal quadrant
of the retina. Many of the patients with primary
vasoproliferative tumours also have systemic
hypertension. Secondary vasoproliferative tumours
on the other hand are bilateral, multifocal and can
be located in any quadrant of the retina. SecondaryFig. 3. B-Scan ultrasound showing acoustically solid tumour.
Fig 2. FFA showing CMEFig. 1. Fundus pictureshowing thevasoproliferativetumor mass
308 Kerala Journal of Ophthalmology Vol. XXI, No. 3
tumours also tend to be more ill defined and
diffuse 7.
These tumours are believed to represent gliovascular
proliferations with varying degrees of both gliosis and
vascular proliferation. Histopathology of these tumours
shows them to be composed predominantly of
elongated, spindle shaped cells, corresponding to glial
cell origin imposed over a fine capillary background.
Mitotic figures, pleomorphism or cellular atypia has
not been shown to be present.Another important
feature of these tumours is the presence of dilated blood
vessels within the tumour mass 2,5.
Various treatment options have been described for
vasoproliferative tumours like periodic observation 1,2,
cryotherapy 1,2 ,3,4, laser photocoagulation 1,4 and plaque
radiotherapy 1,2,8. Some reports suggest that these
tumours may be treated successfully with photodynamic
therapy. Vitrectomy may also be needed for
complications accompanying these tumours like
vitreous haemorrhage and retinal detachment.
Irvine F et al 9 have suggested that trans scleral resection
be attempted if there is difficulty in diagnosis. This
would give tissue for diagnosis and also avoid
unnecessary enucleation in case of diagnostic dilemma.
In conclusion, vasoproliferative tumours should be
included in the differential diagnosis of any peripheral
retinal tumour. They should be recognized by their
distinctive clinical features and angiographic
characteristics and being decidedly benign their
recognition would avoid unnecessary morbidity for the
patient.
References
1 Shields CL, Shields JA, Barret j, et al. Vasoproliferativetumours of the ocular fundus. Classification and clinicalmanifestations in 103 patients.Arch Ophthalmol1995;113:615-23.
2 Heimann H,Bornfeld N,Vij O,Coupland SE,Bechaakisne,Kellner U, Forster MM. Vasoproliferative tumours ofthe retina. Br J Ophthalmol 2000;84:1162-1169.
3 Bianciotto C, Shields CL. Retinal vasoproliferativetumour with associated cystoid macular edema treatedwith cryotherapy and intravitreal triamcinolone.RetinaToday 2008;77-78.
4 Shields JA . Ocular oncology essentials. Retinalphysician 2006.
5 Jain K, Berger A R,Yucil Y H, McGowan H D.Vasoproliferative tumours of the retina.Eye2003;17:364-368.
6 Dunbar MT. Is only seeing eye now threatened ?. Reviewof Optometry Vol. No: 141: 04 Issue 4/15/04.
7 Shields JA, Shields Cl.Intra ocular Tumours: An atlasand text book 2007;396-398.
8 Cohen VM, Shields CL, Demirci H, Shields JA. Iodine I125 Plaque radiotherapy for vasoproliferative tumoursof the retina in 30 eyes.Arch Ophthalmol 2008;126(9):1245-51.
9 Irvine F, O Donnell N, Kemp E, Lee WR. Retinalvasoproliferative tumours:surgical management andhistological findings.Arch Ophthalmol 2000;118:563-569.
September 2009 Kerala Journal of Ophthalmology 309
Go Green for a Healthier LifeDr. Meena Chakrabarti MS DO DNB
The news is crystal clear: After decades and decades of
polluting our surroundings, the planet is suffering.
Scientists have been very vocal about the impact our
driving, manufacturing, and consumption is having on
the future environment, like melting icebergs, rising
ocean levels, and a disappearing ozone layer. Indeed,
“global warming” and “greenhouse gases” have become
regular parts of our vernacular.
The most comprehensive modeling yet carried out on
the likelihood of how much hotter the Earth’s climate
will get in this century shows that without rapid and
massive action, the problem will be about twice as
severe as previously estimated six years ago - and could
be even worse than that.
American Meteorological Society’s Journal of Climate,
indicate a median probability of surface warming of
5.2 degrees Celsius by 2100, with a 90% probability
range of 3.5 to 7.4 degrees. This can be compared to a
median projected increase in the 2003 study of just
2.4 degrees. The difference is caused by several factors
rather than any single big change. Among these are
improved economic modeling and newer economic data
showing less chance of low emissions than had been
projected in the earlier scenarios. Other changes include
accounting for the past masking of underlying warming
by the cooling induced by 20th century volcanoes, and
for emissions of soot, which can add to the warming
effect. In addition, measurements of deep ocean
temperature rises, which enable estimates of how fast
heat and carbon dioxide are removed from the
atmosphere and transferred to the ocean depths, imply
lower transfer rates than previously estimated.
Now, the question being asked is can the damage be
reversed? Experts are unsure of a definitive answer,
but they all agree that if individuals assume a certain
level of personal responsibility, the future will be
cleaner.
With more than 200 million cars on the roads, it is
evident that we have a love affair with the automobile.
Whether it is in a luxury sedan, massive sports utility
vehicle, racy speedster, or cost-conscious compacts, we
enjoy driving. That infatuation, however, has come with
a heavy price tag of urban congestion and plenty of
pollution.
The problem develops when gasoline burns because it
produces a byproduct of nearly 20 pounds of carbon
dioxide (CO2) for each gallon of fuel. CO
2 is one of the
dominant chemicals in greenhouse gases and a major
contributor to global warming.
On a closer level, tailpipe emissions react with sunlight
and oxygen to create ground level ozone. Not
surprising, heavy loads of this toxic gas are prevalent
in major cities and so we live in areas with poor air
quality.
First, check out hybrid automobiles. These cars operate
off both gas engines and electric motors. The electric
motor supplies added power during acceleration,
thereby allowing designers to install smaller traditional
engines. Ultimately, they consume less fuel, which saves
you cash and cuts down on CO2 emissions.
If you drive a totally gas-powered vehicle, you can still
minimize the negatives. One of the best ways to
downgrade its polluting potential is to upgrade your
COMMUNITY
OPHTHALMOLOGY
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
310 Kerala Journal of Ophthalmology Vol. XXI, No. 3
vehicle’s performance. Schedule regular service
appointments to change oil, belts, and filters. For
example, a clogged air filter can decrease your mileage
by 10%.
Also, measure your tire pressure every few months or
before each long-distance trip. Proper inflation saves
you approximately 3% in fuel costs, and provides you
with a safer drive. Under-inflated tires are more
susceptible to damage, such as flats and blowouts—
two things you definitely want to avoid when heading
to a new job. Remember to refer to your car’s operating
manual or contact a trusted mechanic before attempting
any major maintenance. Other simple, but earth-
friendly, motoring techniques include engaging cruise
control on long stretches and avoiding rapid
acceleration or braking If you drive a totally gas-
powered vehicle, you can still minimize the negatives.
For one thing, recycling pays. Items such as paper,
newspapers, cardboard, glass, plastic, and aluminum,
can be broken down and repurposed into other useful
products. And, we use a lot of these substances . Instead
of expending energy and natural resources to create
new containers, recycling one glass bottle saves enough
power to light a 100-watt bulb for up to 4 hours. One
recycled aluminum can has the potential to save enough
energy to run a television or computer for 3 hours.
Fortunately, many municipalities and apartment
complexes have turned recycling into a simple process
by supplying bins dedicated to specific items. All you
have to do is separate the various pieces from the
regular trash. If your apartment organization does not
yet recycle, volunteer to work with the management
to help set up and promote a new system.
You also can go green by turning off and
unplugging. Sure, it is common sense to switch off a
light or television when leaving a room, but it’s even
better to unplug major electronics and appliances when
not in use. Does your coffee pot really need to be
plugged in while you are on duty for 12 hours?
Also, your computer, printer, and cell phone charger
eat up energy when left plugged in and not turned on.
That is a phenomenon known as vampire power,
and is estimated to waste nearly millions in electric
bills each year. Swapping incandescent light bulbs for
the long-lasting, energy-efficient compact fluorescent
type is another money saving and eco-friendly tip. These
are designed to use 75% less energy, and boast of a 10
times longer life cycle.
Energy is not the only commodity you can affect. Water
is another resource in need of conservation—case in
point, several parts of the world suffered devastating
droughts this past summer. While you have no control
over Mother Nature, you can do your part by taking 4-
minute showers, and turning off the faucet while
brushing your teeth or sudsing your hands.
Also, postpone running washers and dishwashers until
you have full loads, and look for phosphate-, petroleum,
and chlorine-free detergents to avoid feeding
unnecessary chemicals into local water systems. Using
either cold or warm water temperature settings can
prevent an estimated 350 pounds of CO2 production
because you minimize the energy used to heat the water.
These simple steps can be followed at home, in
apartment laundry centers, or in coin-operated
Laundromats.
Taking control of your thermostat is yet another green
habit. Researchers believe that for every two degrees
you lower the thermostat, the atmosphere is saved from
approximately 350 pounds of CO2. The general advice
is to set your house temperature for 68 degrees during
winter days, and slightly lower at night and pile on the
blankets. Also, if you have access, clean your heater’s
filters every few months or sooner.
On hot days, the opposite theory applies. Cool off with
an oscillating or ceiling fan, both of which use less
power than an air conditioner (AC). If you must chill
out, limit your AC usage. For a central air system, set
the thermostat high, around 78 degrees, and run
window units for fewer, shorter operating cycles.
To help maintain a comfortable climate, rely on your
curtains or blinds. In the winter, open them up to let
the sunlight warm your rooms, and do the opposite in
summer to keep the heat out.
On your own, follow these simple policies. Start off by
bringing in your own coffee mug or refillable water
bottle instead of choosing disposable cups or plastic
bottles. You can save money and act eco-friendly by
bringing your lunch with you to work on most days. If
September 2009 Meena Chakrabarti - Go Green for a Healthier Life 311
you plan to brown bag it, literally, reuse that bag as
much as possible. Even better, buy a soft insulated
lunchbox. These tend to be easy to clean and keep food
hot or cold. Store food in containers or wash out and
reuse plastic storage bags whenever feasible. A healthy
byproduct? You control what you eat.
What better way to acquaint yourself with a region than
through sampling the local cuisine? Buying locally
grown produce, flowers, and other items helps cut down
on transportation of goods over highways while also
supporting the regional economy. Wherever you grocery
shop, skip the plastic or paper debate and pack up your
own canvas bags. This will reduce the number of plastic
items ending up in landfills.
On everyday items, look for green products. Some
brands promote the fact that they are environmentally
friendly. For others, there are a few simple rules to abide
by, such as choosing pump sprays over aerosols and
picking up brown coffee filters instead of the traditional
bleached white ones. If you do buy something in a
plastic bottle, such as body lotion, flip it over and look
for a number. This is an indicator about which type of
plastic was used to create it. No number means the
item isn’t recyclable.
Finally, put your money where it counts. There are
numerous organizations that work toward protecting
the planet through research, lobbying, and raising
public awareness.
Making it work
The planet’s future is yet to be written, but for
now, the message is fairly clear: Do what you can to
minimize the negative impact. Going green may
take some effort at first, but you will most likely find
that it quickly becomes force of habit, no matter where
you are.
Being Green
• When shopping for a new car, consider
a hybrid model.
• Schedule regular maintenance to change out filters
and oil
• Check tire pressure
• Ease up on the pedals and drive at consistent speeds
• Recycle whenever possible
• Unplug unused electronics and appliances
• Adjust thermostat to seasons
• BYOL: Bring your own lunch (and coffee mug)
• Buy local products
• Use canvas bags when shopping
• Donate to environmental organizations
312 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Masquerade SyndromeDr. Meena Chakrabarti MS DO DNB
Masquerade syndrome includes a group of malignant
and non-malignant systemic or primary ocular disease
that clinically present in the eye as an intraocular
inflammation or uveitis
Uveitis Masquerade accounts for 5 % of patients with
uveitis in a tertiary care centre. An awareness of the
presence of and early recognition of the masquerade is
of utmost importance as Ocular Masquerade may be
the first sign of a life threatening disease.
The various conditions that can manifest in the eye as
a masquerade includes
MALIGNANCIES
Adults:
Primary Central Nervous System lymphomas /
Primary Intra Ocular lymphomas
Systemic NHL Metastatic To The Eye
Metastatic Carcinoma : Breast / Lung / Renal
Uveal Melanomas
Children:
Leukaemia
Retinoblastoma
Medulloepithelioma
Juvenile Xanthogranuloma
NON-MALIGNANT MASQUERADE
Intraocular foreign body / Retinal Detachment /
Retinitis pigmentosa / Pigment Dispersion Syndrome
/ P. Acnes Infection
Many entities present as chronic intraocular
inflammation and a thorough workup to exclude a
masquerade syndrome should be carried out in the
following situations.
1. All undiagnosed inflammatory disease
2. Intraocular inflammations with atypical clinical
features and course
3. Inflammations that do not respond to adequate
medical therapy
4. Age <5 years />50 years
Because of the nature of the underlying disease, which
has detrimental consequences, early diagnosis and
prompt treatment are critical.
This photoessay is on primary intraocular lymphoma
(PIL)
Primary Intraocular Lymphoma is the commonest
condition presenting as an ocular masquerade.PIOL is
a large B cell Non Hodgkin Lymphoma, presenting in
the 5th to 7th decade in immunocompetent persons.
Presentation in an younger age group is seen in the
immunocompromised.This entity is commonly
associated with CNS lymphoma and rarely with visceral
and nodal lymphoma. This condition is bilateral in
80 % of cases. The ocular presentation may be varied
and may manifest as vitritis, sub retinal and sub RPE
creamy white infiltrates, vasculitis, retinitis or as an
uveal mass lesion.
90 % of patients with PIOL develop CNS Lymphoma
while only 5 % of patients with CNS Lymphoma will
develop intraocular manifestations. Hence a detailed
systemic workup, neurological investigations,
PHOTO
ESSAY
Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
September 2009 Meena Chakrabarti - Masquerade syndrome 313
Fig. 1. a-c : (a) Fundus picture at presentation showing optic nerve infiltration in Primary Intraocular lymphoma. (b)Histopathological evidence of large B cells in vitreous biopsy specimen (c)Fundus photograph comparing the lesion
before and after radiotherapy.
like cranial MRI and lumbar puncture are essential.
Vitreous biopsy, sub retinal or subRPE aspirates or a
retinochoroidotomy may be necessary for
histopathological confirmation.
Treatment recommendations depend on whether the
lesions are confined to the eye alone both eye and CNS
involvement or there is recurrence following primary
therapy.
Treatment recommendations:
1. Intraocular Lymphoma alone
XRT to eyes only Systemic Chemotherapy
2. Intraocular and CNS Lymphoma
XRT to eyes + / - BRAIN
Systemic Chemotherapy
Table 1. Scheme of Investigating a patient withchronic Intraocular Inflammation
3. Recurrent Intraocular Lymphoma
Intravitreal salvage chemotherapy with Methotrexate,
Rituximab, Anti CD-20 Monoclonal antibody. Requires
314 Kerala Journal of Ophthalmology Vol. XXI, No. 3
multiple intravitreal injection and carry a very high
recurrence rate on cessation of therapy.
The first case shows regression after radiotherapy in a
biopsy proven case of primary intraocular lymphoma
which presented as disc inflitration, disc edema and
vitritis. Vitreous biopsy specimen showed large B cells
suggestive of PIOL. Note that regression of the lesion
is unfortunately associated with optic atrophy as
evidenced by the disc pallor and functional loss in this
patient. (Fig. 1 a-c)
Fig. 2. a-c . (a) Fundus picture at presentation showing the creamy subretinal infiltrates temporal to the macula in a patientwith PIOL. (b)Hitopathological confirmation of large B cell infiltrates in the chorioretinal biopsy speciemen(c)Comparative fundus pictures before and after systemic chemotherapy showing good resolution and residual RPEscarring
The second case presented as creamy subretinal
infiltrates temporal to the macula in a 55 year old
male patient who attended our clinic with complaints
of defective vision and floaters. Vitreous biopsy
and chorioretinal biopsy specimen showed large
B cells suggestive of PIOL. This patient was managed
by systemic chemotherapy and showed good
resolution of the lesion with residual rpe scarring
(Fig 2 a-c).
September 2009 Meena Chakrabarti - Masquerade syndrome 315
Management of A Case of Post-traumatic
Cyclodialysis With CataractDr. Mohan Rajan MS 1, Dr. Andrew Braganza MS 2, Dr. Arup Chakrabarti MS 3, Dr. V. Sahasranamam MS 4,
Dr. Simon George MS 4
A 48 year old diabetic lady was seen in our OPD with
complaints of defective vision right eye following a
closed globe injury (blunt trauma) 3 years back. She
was having moderate visual loss at that time and was
being treated by ophthalmologists at two local hospitals.
Available records show that she was on systemic
steroids for some time.
Presently examination of her right eye revealed a clear
cornea, dilated non reacting pupil, mature (white)
cataract with phacodonesis. IOP recorded was 4mm of
Hg in the right eye and vision was perception of light
with accurate light projection. Gonioscopy revealed
cyclodialysis from 9’O’clock to 2’O’clock. The
cyclodialysis was confirmed by UBM.
B Scan did not show any retinal detachment.
Left eye was normal, BCVA of 6/6.
How would you approach this case?
Dr. Mohan Rajan
Cyclodialysis clefts are due to disinsertion of the
longitudinal fibres of the ciliary body from the scleral
spur. They can occur following blunt trauma or due to
surgery for cataract or glaucoma.The result is a
communication between the anterior chamber and the
suprachoroidal space which results in internal filtration
and therefore hypotony. Hypotony causes choroidal
effusions, macular / optic disc edema and decreased
visual acuity. Later generalised detachment of the ciliary
body occurs which results in decreased aqueous humour
production which further aggravates hypotony.
The goal of treatment is to reverse hypotony and restore
visual function. The indications for treatment of
cyclodialysis include hypotonous maculopathy, macular
folds, choroidal detachment, corneal edema &
worsening vision. A cyclodialysis cleft with hypotony
but without structural or functional abnormalities does
not require treatment. The management algorithm
includes treatment by medical, laser or surgical
methods.
Medical management consists of apposition of ciliary
body against the scleral spur and promotion of
adherence by scar formation. This is enhanced by strong
mydriasis ( 1% atropine eye drops) and minimising /
stopping of steroid medication for up to 6 weeks.
Noninvasive laser methods include treatment by argon
laser to the ciliary body and sclera through a goniolens.
If visualisation of the cleft is difficult due to shallow
anterior chamber, the chamber can be deepened with
viscoelastics prior to the procedure.Joondeph who did
the first argon laser treatment used powers of
400-800mw, 200 micron spot and 0.1-0.2 sec exposure
time. Other noninvasive methods include use of
transcleral yag / diode laser,transcleral cryotherapy.
If medical /noninvasive laser methods do not work then
sugical methods become the next option. Methods
adopted depend on the size of the cleft. Small clefts
<2 clock hours can be approached by direct /indirect
cyclopexy or ciliochoroidal diathermy. Medium clefts1Chennai 2 CMC , VELLORE, 3Chakrabarti Eye Care Centre, Kochulloor, Trivandrum4 RIO, Trivandrum
CONSULTATION
SECTION
316 Kerala Journal of Ophthalmology Vol. XXI, No. 3
of 2-4 clock hours need to be approached by direct
cyclopexy or diathermy. Large clefts >4 clock hours
can be approached by direct cyclopexy or by anterior
scleral buckling. Large chronic clefts are reported to
benefit from parsplana vitrectomy, cryotherapy and gas
tamponade.Delay of treatment for> 8 weeks increases
the risk of loosing 1-3 snellen lines of visual acuity.
With respect to our patient, medical management with
Atropine eye drops and transcleral diode laser in two
rows of contiguous burns 2 to 3mm behind the limbus
or argon laser photocoagulation. Following this since
the patient has mature cataract, phacoemulsification
and implantation of nonfoldable intraocular lens in the
ciliary sulcus will enhance closure of the Cyclodialysis
cleft. If the above treatment fails then direct repair of
the cleft is recomended. In cases of traumatic
cyclodialysis there could be alterations in the
iridocorneal angle which persists after cyclodialysis
repair and therefore regular monitoring of intraocular
pressure is recommended.
Dr. Andrew Braganza
This is a very interesting clinical scenario. One more
piece of information I would like is to know whether
there is a relative afferent pupillary defect in the
affected (right) eye. Even though the pupil is dilated
and non reactive, presumably secondary to traumatic
mydriasis, this information is easily obtained by the
swinging flashlight test and observation of its effects
on the left eye. I assume there is no RAPD and that
therefore there is no significant disc damage in the right
eye.The problems that need addressing are the
following:
1.Cataract
2.Cyclodialysis and hypotony
The traumatic mydriasis may be a problem, but can be
addressed subsequently. Diabetes related ocular
problems is unlikely to be an issue here in view of the
normal fellow eye.
Cataract: The cataract needs to be removed and an
IOL implanted. It is likely that there is extensive zonular
damage, and capsular support for the IOL may be
lacking. I would plan a superior scleral tunnel incision
with the intention of doing a manual small incision
surgery, converting to a sclerally fixated lens if needed.
It is easy enough to pass the sutures needed through
the posterior lip of the tunnel and under a scleral flap
180 degrees away, so that they remain buried under
partial thickness sclera after being tied. Alternatively,
there are techniques available to handle this cataract
by phaco even to the extent of sclerally fixating or iris
fixating a foldable lens. Details of this are outside the
scope of this discussion. Please note that scleral fixation
of the IOL must be done only after repair of the
cyclodialysis
Cyclodialysis: Applying laser treatment or cryo is a
conservative option for a cyclodialysis cleft. With a small
cleft the results are quite good, the advantage of this
approach being that it is non invasive and can be
repeated if it fails, still leaving a surgical option open.
With a large cleft, this treatment is unlikely to succeed;
in this patient, therefore, I would recommend
commitment to a surgical repair, especially as the
cataract surgery has to be done anyway. The technique
involved is similar to scleral fixation of an IOL. A double
armed suture needs to be passed through or just behind
the root of the iris, through the scleral spur and out
under a partial thickness scleral flap and tied, to appose
the dialysed ciliary body to its normal attachment. 10-
0 prolene is a suitable material, though over tightening
must be avoided as the delicate ciliary and iris tissue
cheese-wires quite easily. For a superior cleft like this,
an open-sky approach through a scleral tunnel using
10-0 monofilament nylon on a curved needle is also
possible. The procedure is to some extent blind, as one
cannot directly visualize the exact entry point of the
suture from the inside. But, as with sclerally fixating
an IOL, using external surface anatomy and a 26 or
30G hypodermic needle introduced from outside the
eyeball as a guide, precise placement can be achieved
by railroading the prolene suture through the
hypodermic needle. Many variations of technique have
been described; the reader can study these in detail
and decide for him- or herself which makes the most
sense. With 5 clock hours of dialysis in this patient it is
likely that two separate sutures will be needed for the
repair. If a scleral tunnel incision is being used for the
cataract, it should be possible to pass both these sutures
through the bed of the tunnel without the need for
separate scleral flaps or dissections.
September 2009 R. Sahasranamam et al. - Post-traumatic cyclodialysis 317
Apart from the technical difficulty of the repair, the
challenging part of treating a cyclodialysis is handling
the IOP once the repair is achieved. A steep rise to 40
or 50 mmHg can be expected in the postoperative
period associated with pain and acute danger to the
optic nerve head. Prophylactic administration of
Diamox is obviously not an option in a hypotonic eye.
Early removal of the bandage and checking of IOP
postoperatively, probably within 12 hours of the
procedure is a logical precaution. The initial reversal
and upswing of IOP does eventually stabilize in most
cases, but requires monitoring and treatment; it may
take days to weeks to stabilize and the patient needs to
be closely followed up during this period. Permanent
secondary glaucoma may ensue, and require lifelong
treatment. To my mind this is preferable to macular
damage from hypotony. If surgical control of IOP is
needed later, this would usually take the form of a
glaucoma drainage device, not a trabeculectomy.In this
patient, even assuming that surgery is successful, the
visual prognosis remains guarded. This is because we
don’t know the condition of the macula preoperatively.
Prolonged hypotony may result in permanent damage
and irreversible visual loss.The dilated pupil may cause
the patient problems. If so, an iris implant can be
considered at a later stage.
Dr. Arup Chakrabarti
The given patient presents with a couple of intriguing
problems. The condition of the patient is to be tackled
at two levels.
1. Visual rehabilitation
2. Management of hypotony
Visual rehabilitation
Careful preoperative counseling is mandatory. Patient
is to be informed that non improvement of vision
postoperatively may be related to subtle changes in the
posterior segment which may not be evident
preoperatively in view of the media opacity. Late
postoperative complications may arise because of the
prior trauma unrelated to the cataract surgery. The
extend of subluxation should be evaluated with the
patient in supine position. A scan biometry may be
difficult in view of the hypotonicity. Injection of
viscoelastic through a paracentesis site on the slit lamp
has been recommended prior to gonioscopy. Another
option would be to perform A scan biometry on the
surgical table with sterile precautions. It is preferred
to use peribulbar anesthesia since the surgery is likely
to be complicated and a prolonged one. A temporal
scleral tunnel incision would be appropriate since it
will render conversion to a non phaco technique easier,
should the need arise, due to intraoperative
complications. Anterior capsule must be stained with
trypan blue dye. The capsulorhexis should be performed
with a closed chamber technique preferably with micro
rhexis forceps. Fibrotic anterior capsular plaque may
be seen in similar situations. In difficult situations,
placement of iris hooks may be called for, to support
the capsular bag, during capsulorhexis. Hydrodissection
may perhaps be avoided since this is a traumatic mature
cataract and a preexisting posterior capsular dehiscence
may not be completely ruled out. A good quality
viscoelastic agent should be employed to protect the
endothelium and maintain the anterior chamber depth.
Excessive chamber depth fluctuation should be avoided.
Direct phaco chop would be an ideal technique to
remove the nucleus since it is less traumatic to the
zonules. Vitreous if present should be managed by
automated anterior vitrectomy. A foldable hydrophobic
or hydrophilic acrylic intraocular lens should be
implanted in the capsular bag. After nucleus removal,
it may be a good idea to implant a capsular tension
ring within the capsular bag. A double eyelet Cionni
ring sutured to the sclera may have to be considered if
there is extensive zonular loss.
If the capsular bag stability is inadequate for safe
phacoemulsification, one should think of converting to
a non phaco technique. In that case, the PCIOL may
have to be sutured to the ciliary sulcus (scleral fixation).
There are several techniques available for scleral
fixation and the surgeon can choose a technique he is
comfortable with.
Postoperative evaluation should be intensive since more
than usual post operative inflammation is to be
expected. A thorough evaluation of the posterior
segment should be performed. The postoperative course
may be complicated by retinal detachment as a result
of the prior trauma and the patient should be informed
about it.
318 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Management of hypotony
Patient has to be watched carefully in the postoperative
period. Hypotony is known to have deleterious effects
in the posterior segment including hypotonous
maculopathy. In such a case, the condition may have
to be managed surgically. There are various procedures
described in literature for the treatment of cyclodialysis
clefts which implies that the condition is difficult to
treat. Direct Argon laser photocoagulation through a
gonioprism ( in cases with good visualization) has been
found to be successful by several investigators.
Confluent applications of 100 mm spots at 0.1 to 0.2
sec and 500-1000 mW are delivered to the base of the
cleft followed by postoperative cycloplegics. Repeat
treatment may be required in some cases to
progressively close the cleft. In cases with poor visibility,
the cleft can be treated indirectly from outside by
cryotherapy or photocoagulate it with either a diode
or transcleral Yag laser. All these indirect approaches
require a peribulbar anesthesia for comfort, as well as
post operative cycloplegics.
More aggressive surgical therapy has been described
and involves external diathermy to the bed of the scleral
flap that is created over the cleft. This can be combined
with suturing the cleft with 9-0 or 10-0 nylon through
the scleral bed, either with or without direct
visualization. Recalcitrant clefts may require pars plana
vitrectomy, cryotherapy and tamponade with SF6 gas.
The patient can experience a period of extremely high
pressure and acute pain once the cleft is closed. The
patient should always be warned of this possibility and
prophylactic aqueous suppressants may have to be
prescribed.
In summary, management of this complicated case is
quite complex. Difficulties are expected during cataract
surgery in view of the mature state of cataract,
subluxation and very soft eye. Inspite of a well done
cataract surgery, visual success may not be satisfactory
in view of the posterior segment complications induced
by the blunt trauma. In the event of a persistently low
post operative intraocular pressure affecting structure
and function, cyclodialysis cleft will have to be dealt
with surgically using one of the techniques described.
Compilation
As opined by our expert panel, this is a difficult,
intriguing problem.
Our approach to the problem was, two pronged
1. Tackle the hypotony
2. Visual rehabilitation
In a primary sitting, we planned to take care of the
hypotony. Being a large cyclodialysis cleft, of long
standing , we planned a surgical cyclopexy. Under a
partial thickness sclera flap we did a continuous – 10-
0 nylon(curved needle) suturing of the ciliary body to
its scleral bed. As indicated by our panelists this
procedure, is to a good extent a blind procedure. The
appositioning of the CB to its scleral bed should be
full, to get a desired effect but you can easily cheese
wire through delicate ciliary / uveal tissue. Even a small
cyclodialysis cleft remaining open shall keep the IOP
low and in the other hand you can have raised IOP
post operatively. The balance is delicate. In our case ,
the post op IOP was around 8mm of Hg (1 week and 3
weeks post op).Post-op evaluation revealed
cyclodialysis persisting in one clock hour. Though our
intention was to close the cleft fully,it has not worked
out in one sitting.
Regarding the cataract we planned to deal with it 3
weeks post cyclopexy, but the patient disclosed chicken
pox during this period, which delayed the second
surgery by more than 6 weeks. SICS through a scleral
tunnel made close to the limbus ( to avoid the cyclopexy
site) was done. Through the patient developed a
phacodonesis, intraoperatively, capsulorhexis, lens
nucleus delivery and IOL implantation were uneventful.
The dilated non reacting pupil (traumatic mydriasis)
is persisting. Seen 10 days post op the patient had a
UCVA of 6/36. Fundus examination revealed, normal
disc and vessels with a dull fovea. Post cataract surgery
also, the IOP is in the range of 8mm of Hg.
On 16/9/09 (last follow up, when the patient is
reviewed by her local ophthalmologist at Cochin), the
visual acuity in the operated eye is 6/12 improving to
6/6p with glasses and the IOP is 8.5mm Hg
Compiled by: Dr. V. Sahasranamam and Dr. Simon George, RIO Trivandrum
September 2009 Meena Chakrabarti - Masquerade syndrome 319
A Tribute to Charles L. Schepens, MD
The current practice of
ophthalmology owes a great
debt to Charles Schepens’
passion for science, which
revolutionized ophthalmic
practice by combining
clinical practice and eye
research. He is considered by
many to be the father of
modern retinal surgery, not
to mention the grandfather
of the corneal subspecialty.
He was the brilliant inventor of the indirect binocular
ophthalmoscope, and his devices, as well as surgical
techniques such as scleral buckling, have been credited
with raising the success rate of retinal reattachment
surgery to 90 percent.The Belgian-born Dr. Schepens
began his training in mathematics, which led to his
interest in ophthalmic instrumentation. He received his
medical degree from the University of Gand in 1935
and went on to train at Moorfields Eye Hospital,
London, from 1935 to 1937. He then returned to
Belgium to practice medicine, and in 1939 joined the
medical corps of the Belgian Air Force. After the German
invasion of Belgium in 1940, he became a courageous
leader in the French Resistance who masterminded the
escape through the Pyrenees of more than 100 people.
He was later decorated for bravery by both the French
and the Belgian governments.In 1947, Dr. Schepens
emigrated to the United States and took a fellowship
post at the Howe Laboratory of Ophthalmology at
Harvard Medical School. Two years later, he established
and became the first director of the retina service at
OPTHALMIC
HISTORY
Dr. Meena Chakrabarti MS DO DNB
Fig. 1. The old prototype model of the binocular indirectophthalmoscope invented by Dr. Charles Schepens
Fig.2 The technique of placing staggered rows of diathermy
burns on the bed of the dissected seleral flap was avery efficient form of retinopexy during detachmentrepair surgery popularised by Dr. Schepens.
Fig. 3. The ‘MIRA SERIES’ of silicon buckles and spongeshave withstood the test of time and are used for both
implant and explant procedures.Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 E-mail:
tvm_meenarup@sancharnet.in
320 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Fig. 4. The meridonal buckles (No. 135 & 137) wereextensively used during inplant procedures forpreventing fish mouthing of a large posterior horseshoe tear.
the Massachusetts Eye and Ear Infirmary, the first of its
kind. In 1950, he established the Retina Foundation, a
center for the intensive investigation of retinal
detachment and allied conditions. This illustrious
organization is now known as the Schepens Eye
Research Institute and is the largest independent eye
research organization in the United States, a living
legacy to the basic biomedical and clinical eye research
Dr. Schepens thought so important.(Fig.1 - 4) He was
the author of more than 340 medical papers and four
books, trained more than 170 vitreoretinal surgeons,
gave countless lectures and courses, and received
innumerable honors during his distinguished career.
In 1999, he was selected as one of the 10 Most
Influential Ophthalmologists of the 20th Century by
his peers—33,000 ophthalmologists in the United States
and abroad—for his innovations and inventions that
have so greatly improved ophthalmology. In 2003, he
was honored as an inaugural recipient of the American
Academy of Ophthalmology’s highest honor, the
Laureate Recognition Award.He had an unlimited
amount of kinetic energy and seemed always focused,
engaged, passionate and driven. He was quite engaging,
and never forgot anything about anyone he ever met.
In his presence, you could feel the energy he radiated—
the fire of so many things to do and questions to be
answered. This energy was contagious, and gave him
the ability to inspire others with his passion and
enthusiasm. He created in every one a sense of the
importance of the projects in which we were involved.
His logical thought processes, attention to detail and
formidable intellect are legendary.Of course, Dr.
Schepens will be missed, but we are fortunate that so
much of his energy and passion persist in the many
physicians and researchers he inspired.
September 2009 Journal Review 321
Photodynamic Therapy for Age-Related
Macular Degeneration : Epidemiological
and Clinical Analysis of a Long –Term StudyJorge Mataix, M Carmen Desco, Elna Palacios.
Ophthalmic Surg Lasers Imaging 2009; 40:277-284
Age related macular degeneration (AMD) is a
degenerative dystrophic disease that goes through
several phases in its natural evolution. Its consequences
range from minor forms of dry AMD to severe forms of
exudative AMD with choroidal neovascularization, in
which more serious loss of vision occurs. CNV is a self
limiting lesion that grows progressively, producing a
serious injury to the retina, until a disciform scar
appears. There are different and multiple treatments
to stop this disease, but photodynamic therapy is the
only one with long term follow up. The clinical results
of PDT can be of great interest and potential concern
to clinicians as a basis of comparative efficacy of new
treatments.
The principal aim of this prospective non randomized
clinical trial from Valencia, Spain was to analyze the
long term results of patients with exudative age related
macular degeneration treated with photodynamic
therapy. 262 patients were included with exudative age
related macular degeneration who were treated with
PDT in accordance with a protocol of the Treatment of
Age Related Macular Degeneration with Photodynamic
Therapy Study. The follow up lasted 48 months.
There was significant loss of visual acuity 3 months
after the first PDT treatment, a slow progressive
decrease of vision until month 12, and then visual acuity
remained stable from months 24 to 48.The choroidal
neovascularization size increased noticeably during the
first 12 months, particularly the first 3 months after
PDT. The higher the classic component of choroidal
neovascularization, the better it responded to PDT. The
evolution of juxtafoveal choroidal neovascularization
was worse than that of subfoveal choroidal
neovascularization after PDT because it grew quickly
towards the fovea and visual acuity loss was greater.
The authors conclude that PDT is a safe, long term
treatment for exudative age related macular
degeneration, but it is not definitive because this
treatment cannot stop the initial growth of the choroidal
neovascularization lesion. Future studies on long term
visual acuity changes for exudative AMD treated with
antiangiogenic drugs will show us the difference with
PDT treatment for this disease.
JOURNAL
REVIEW
322 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Refractive Errors and Strabismus in Children
with Down Syndrome: A Controlled StudyArsen Akinci, Ozgur Oner, Ozlem Hekim Bozkurt.
J Pediatr Ophthalmol Strabismus 2009;46:83-86.
Corneal Collagen Cross Linking Using
Riboflavin and Ultraviolet-A Light For
Keratoconus : One-year Analysis Using
Scheimpflug ImagingDilraj S Grewal, Gagandeep S Brar, Rajeev Jain , Vardaan Sood.
J Cataract Refract Surg 2009; 35:425-432.
There is a mounting evidence of the efficacy of corneal
collagen cross linking treatment using photo sensitizer
riboflavin and ultraviolet-A(UVA) light with wavelength
of 370 nm in halting the progression of keratoconus
and post refractive surgery corneal ectasia with minimal
toxicity. This study from Grewal Eye Institute,
Chandigarh aim to evaluate changes in corneal
curvature, corneal elevation, corneal thickness, lens
density and foveal thickness after corneal collagen cross
linking with riboflavin and ultraviolet-A light in eyes
with progressive keratoconus.
This study recruited 102 patients older than 18 years
with a corneal thickness of atleast 400 μm diagnosed
with progressive keratoconus. All patients had
subjective refraction, best corrected visual acuity(BCVA)
measurement, Pentacam rotating Scheimpflug imaging
and OCT imaging before cross linking and 1 week,1,3
and 6 months and 1 year after cross linking .The mean
preoperative BCVA remained stable from preoperative
levels in all postoperative visits. The mean spherical
equivalent decreased steadily postoperatively to a low
of -4.90±3.52D at 1 year. The mean cylinder vector
was 1.58×7º±3.8D before cross linking and
1.41×24º±3.5D, 1 year after cross linking. There was
no significant difference in mean measurements
between preoperatively and 1 year postoperatively,
respectively for Central Corneal Thickness (CCT)
(458.9±40μm and 455.2± 48.6μm), anterior corneal
curvature (50.6±7.4D and 51.5±3.6D), posterior
corneal curvature (-7, 7±1.2D and -7.4 ±1.1D) apex
anterior (p=.9),posterior corneal elevation (p=.7), lens
density( p=.33) foveal thickness (175.7±35.6μm and
146.4±8.5 μm; p=.1).
Stable BCVA, spherical equivalent, anterior and
posterior corneal curvatures and corneal elevation
one year after cross linking indicate that keratoconus
did not progress. Unchanged lens density and foveal
thickness suggest that lens and macula were not
affected after UVA exposure during cross linking.
Authors admit that this study included limited number
of patients with limited follow up. Long term stability,
indications and contraindications of riboflavin- UVA
collagen cross linking must be evaluated.
Ocular manifestations of Down syndrome have been
well described in numerous studies and include eyelid
anomalies such as prominent epicanthal folds, upward
slanting of palpebral fissures, epiblepharon,
September 2009 Journal Review 323
Compiled by Dr. Reesha, Little Flower Hospital, Angamaly
nasolacrimal duct obstruction, blepharitis, keratoconus,
retinal abnormalities, glaucoma and amblyopia due to
strabismus, refractive errors, and media opacities.
However in all these studies an appropriate control
group was lacking and the authors compared their
findings with previous normative studies. In this study
authors from Boston aim to evaluate the prevalence of
refractive errors, strabismus, nystagmus and congenital
cataract in children with Down syndrome and control
subjects of similar age and socioeconomic group.
Seventy seven children with Down syndrome and 151
control subjects were evaluated for the prevalence of
ocular findings. The diagnosis of Down syndrome was
made through clinical and genetic findings. All children
underwent cycloplegic auto refraction, retinoscopy, or
both, slit lamp biomicroscopy and detailed fundus
examination. Ocular movements were checked and
ocular alignment was assessed by Hirschberg corneal
reflex test, Krimsky prism test or prism cover test. Ocular
findings were discovered in 97.4% of children with
Down syndrome and 42.4% of control subjects
(p<.0001). The point prevalence of nystagmus,
strabismus, hypermetropia, astigmatism and congenital
cataract was significantly higher in children with Down
syndrome (p<.0001 for first four categories, and p<.01
for congenital cataract).
The authors conclude that evaluation , treatment and
regular review of ocular and refractive findings in
children with Down syndrome is essential and likely to
significantly enhance the quality of life of individuals
with Down syndrome.
324 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Manual of SQUINTAuthor Leela Ahuja, Ex- Professor of Strabismology, Ex- Director, Institute of Ophthalmology
Aligarh Muslim University, Aligarh, UP
Published by Jaypee Brothers, New Delhi
First Edition, 2008
Price - Rs; 350/-
Most controversial aspects of certain condition have
been deliberately left out for the sake of easy
understanding. This book includes materials from Duke
– Elder, Kyeth Lyle, von Noordan, Kanski, Muller and
Peymann.
This book gives a reasonable background for
understanding the ocular muscles and their functional
anomalies. The surgeon’s update knowledge of the
subject, efficiency and dedication alltogether can find
solution to the squint problem. Appropriate diagrams,
figures and photographs have been provided in this
book. I do hope the postgraduates are benefited by
going through this work, not only during the course of
their formal study but also, subsequently in their
practices.
A lot of literary works have been done on squint but
still there is a dearth of standard books on strabismus
for post graduate students. No doubt, surgery of squint
is done by many ophthalmologists, but mostly, it is on
cosmetic grounds and that too without the help of
proper orthoptic department. It is also a fact that general
public is reluctant to have treatment, particularly surgical
treatment of squint, as this malady is considered to be
due to displeasure of some goddess. The importance is
not to cure deviation, but to improve binocular function.
The prevalence of squint in Indian population is estimated
to be 3- 4 % and prevalence of amblyopia 1%.
Squint topics are very much comprehensive so the
author has tried to simplify them by providing their
description in simple and easily understood language.
Ophthalmology Secrets In ColorAuthors James F. Vander MD, Janice A. Gault, MD, FACS
Published by, MOSBY ELSEVIER, New Delhi
Third Edition – 2009
Price Rs: 850/-
Much of the information in this book can be found in a
number of other ophthalmology text books. The table
of contents is similar to that of many other books already
in print. So why bother to write a new ophthalmology
text? The value of the book is in the unique manner in
which the material is presented, continuing the tradition
the Secrets Series has established in numerous other
specialties. The question – and – answer “Socratic Method”
format reflects the process by which a large portion of
clinical medical education actually takes place.
This completely updated top – seller in ophthalmology
continues the tradition of the highly popular Secrets
BOOK
REVIEW
September 2009 Book Review 325
Series. From basic science to visual fields and refraction,
from the basic eye exam to discussions of all
ophthalmologic disorders, from contact lenses to
corneal transplantation, problems of the aging eye and
pediatric disorders – this book presents all the key
elements of ophthalmology for clinical use, rounds, and
board preparation.
� Presents figures in full color for enhanced visual
guidance
� Expedites reference and review with a question –
and – answer format, bulleted lists, mnemonics,
and tips from the authors.
� Features a two – color page layout, “Key Points”
boxes, and lists of useful web sites to enhance
your referencing power.
� Includes a chapter containing the “Top 100
Secrets” in ophthalmology, enabling you to quickly
review essential material.
� Comes in a pocket size for easy access to key
information.
No matter what questions arise, whether preparing for
examinations or in practice, Ophthalmology secrets, 3rd
Edition, has the answers you need
Dr. Hoyos’s Step by Step Lamellar
Corneal GraftEdited by Eduardo Arenas, Jairo E Hoyos
Published by Jaypee brothers New Delhi
First Edition-2008
Price Rs: 595/-
The time for lamellar keratoplasty has finally arrived;
an old surgical procedure has always been outshined
by the more glamorous technique of penetrating
keratoplasty. Lamellar keratoplasty (LK) has fallen in
and out of favor, being regarded as a tectonic procedure
or as graft for superficial corneal scars. The editors of
this book, Arenas and Hoyos, are experienced corneal
surgeons, well known writers and editors of scientific
articles. They have seen the need for this publications
and have undertaken the formidable task of putting
together actual information about a variety of
techniques and indications for partial lamellar
keratoplasty, some so revolutionary that they are still
unknown in some medical centers. To this effect, they
have obtained collaboration of a group of
internationally known corneal surgeons to write
specialized chapters.
The numerous papers included in this book illustrate
the multiple techniques and indications for this type of
surgery at the present time. Some procedures were not
even dreamed of a few years back, expect in the minds
of a few that were ahead of their time.
The table of contents shows what pathologists call “sequence
of events”; in this case, how a procedure has been
gradually changed and perfected through the years with
the help of new ideas and technical innovation.
This review of the most recent lamellar keratoplasty
techniques will be informative for the anterior segment
surgeon.
326 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Manual Small Incision Cataract Surgery
(MSICS)Edited by Ashok Garg, Francisco J Gutierrez-Carmona, Luther L Fry, Amulya Sahu, M S Ravindra
Published by Jaypee Brothers New Delhi
First edition – 2008
Price Rs 395/-
This book is mainly dedicated to describe several
manual techniques including nuclear manipulation
or fragmentation, fragment extraction, strategies in
the use of several viscoelastic devices, the use of an
anterior chamber maintainer, etc. A whole chapter on
complications and their avoidance is also included.
In other words, the reader will find many ideas to either
learn or enrich from this manual small incision cataract
surgery mini atlas.
This Mini Atlas on MSICS shall be invaluable
companion to ophthalmologists as ready reckoner
in operation theatre and clinical OPD for quick
review.
Manual Small Incision Cataract Surgery (MSICS) has
improved significantly with the passage of time. Similar
visual results can be obtained as with phaco with much
lesser costs. Being proficient in MSICS not only makes
the ophthalmologists independent of machine technology
but also it has many other advantages as it is very useful
in difficult situations like hard cataracts. Proficiency in
MSICS makes the transition to phaco emulsification much
easy. This Mini Atlas of MSICS contains 15 chapters
covering various techniques of MSICS beautifully by
International Masters of this field. All MSICS techniques
are described with more figures step by step for better
understanding. Video DVD ROM provided with this book
shows various important MSICS techniques by experts
in this field.
Basic OphthalmologyAuthor - Renu Jogi
Published by Jaypee Brothers
Fourth Edition – 2009
Price Rs: 895/-
The need for a textbook for undergraduate medical
students in ophthalmology dealing with the basic
concepts and recent advances has been felt for a long-
time. Keeping in mind the changed curriculum, this
book is intended primarily as a first step in commencing
and continuing the study for the fundamentals of
ophthalmology. In essence, Basic Ophthalmology is both
a ‘text book’ and a ‘note book’ that might as well have
been written in the student’s own hand. The idea is for
the student to relate to the material; and not merely to
memorize it mechanically for reproducing it during an
examination. The past few years have witnessed not only
an alarming multiplication of information in the field
of ophthalmology, but more significantly, a definite
paradigmatic shift in the focus and direction of ophthalmic
research and study. The student will thus find a new
section devoted to a discussion on Visual Display
Terminal Syndrome (VDTS) that is an outcome of excessive
exposure of the eyes to the computer monitor as well
as the use of contact lenses. Two additional sections deal
with the Early Treatment for Diabetic Retinopathy Study
(ETDRS) classification and Scheie’s classification for
hypertensive retinopathy that replaces the pre-existent
taxonomy prevalent for little less than seven decades.
September 2009 Book Review 327
Salient features of this book are:
� Fully revised and updated.
� Written as per syllabi of Indian Universities.
� Presents the basic aspects as well as recent
advances in ophthalmology comprehensively.
� Highlights Visual Display Terminal Syndrome and
Compiled by Dr. C.V. Andrews Kakkanatt, JMMC, Thrissur
ETDRS and Scheie’s classifications of hypertensive
retinopathy as new additions.
� Covers more than 500 MCQs with answers for easy
recall of the concepts.
� Useful for graduate and postgraduate students and
teachers as well as practicing ophthalmologists.
ERRATUM
In the June 2009 issue an error in the names of the authors for the articlein Community Ophthalmology was inadvertently published. We sincerelyapologise for this error
The corrected names of authors are
1. Dr. [Mrs.] R. Jose MD 2. Dr. Sandeep Sachdeva MD, DNB
CME Programmes
STATE CONFERENCES
DRISHTI 2009
36th Annual Conference of Kerala Society of
Ophthalmic Surgeons
27-29 th November 2009
Dinesh Auditorium, Thana, Kannur
Dr.Sreeni Edakhlon
9895618170
NATIONAL CONFERENCES
FOCUS 2009
XXIX th Annual Conference of the Maharashtra
Ophthalmological Society & XVIIth Annual Conference
of the Bombay Ophthalmologists’ Association
25-27th September 2009
ITC Grand Maratha Sheraton, Hyatt Regency and Le
Royal Meridien, Sahar, Mumbai
Dr.Ragini Parekh: 9867872333
Kalpavriksha 2009
National PG CME Programme
October 1-4, 2009
Organizer: Dr.Agarwal’s Eye Hospital, Chennai
VISTA 2009
XIX Annual Conference of the
Glaucoma Society of India
November 6 – 8, 2009
Nimhans Convention Centre
Bangalore
Dr.Gowri J Murthy: 080-26722215
KSOC 2009
28th Karnataka State Ophthalmic Conference
November 27-29, 2009
J.J.M Medical College, Davangere
Dr.Rajesh.P: 9845568791
AIX 2010
68th Annual conference of
All India Ophthalmological Society &
15th Afro Asian Congress of Ophthamology
21-24th January 2010
Science city Kolkata
Dr. Ashish K. Bhattacharya
www.aioc2010.com
INTERNATIONAL CONFERENCES
XXVII Congress of the Europian Society of Cataract and
Refractive Surgeons
12-16th September 2009
Barcelona, Spain
www.escrs.org
AAO-PAAO 2009
24-27th October, 2009
Sanfrancisco
www.aao.org/2009
ASCRS.ASOA
Boston 2010
9- 14th April 2010
www.ascrs.org / www.asoa.org
UPCOMING
CME
Glaucoma Drugs and Dry - Eyes
Complications
Potential ocular and/or systemic adverse effects:
• Prostaglandin Analogues: stinging, blurred vision, eye redness,itching, burning, possible changes in eye color and eyelid skin,.
• Beta Blockers: foreign body sensation, photophobia, itching,ocular irritation, low blood pressure, reduced pulse rate, fatigue,shortness of breath; rarely: reduced libido, depression,
• Alpha Agonists: burning or stinging, fatigue, headache,drowsiness, dry mouth and nose, relatively higher likelihood ofallergic reaction.
• Carbonic Anhydrase Inhibitors: in eye drop form: stinging,burning, eye discomfort; in pill form: tingling hands and feet,stomach upset, memory problems, depression, frequenturination.
Prevalence of Dry Eye in Glaucoma Patients
• Patients with open-angle glaucoma also have symptoms ofconcurrent ocular surface disease.
• Dr Leung studied 101 patients with either open-angle glaucomaor ocular hypertension.
• 60 patients (59 %) reported dry eye symptoms in at least oneeye, and 27 patients (27 %) reported severe dry eye symptoms.
• Schirmer testing - 62 patients (61 %) experienced reduced tearproduction in at least one eye; 35 patients (35 %) had severetear deficiency.
• Twenty-two patients (22 %) showed positive corneal andconjunctival lissamine green staining results
• Break-up time testing - 79 patients (78 %) showed abnormaltear quality, and 66 patients (65 %) had a severe decrease intear quality in at least one eye.
Glaucoma Drugs and dry eye condition
• Dry-eye condition also could be caused by Glaucomamedication.
• Side effects increase with the frequency of instillations.
• Risk of failure of filtration surgery.
• Subtle signs of ocular toxicity (break up time, superficialpunctuate keratitis) have long term consequences.
• Long term use - conjunctival scarring known as drug inducedpemphigoid.
Dry eye symptoms with Preservatives
• Decrease the stability of the precorneal tear film through a
detergent effect
• Decrease the density of goblet cells in the conjunctival epithelium.
• BAK causes toxic or immuno-inflammatory effect on the ocular
surface.
• Topical preservatives cause inflammation, squamous metaplasia,
and subconjunctival fibrosis in the conjunctiva and Tenon’s capsule.
• These changes could probably also concern the trabeculum
structures.
• Except for beta-blockers, all commercially currently available
antiglaucoma eyedrops contain BAK.
• Preservatives decrease the stability of the precorneal tear film.
• They have a detergent effect on the lipid layer, resulting in
increased evaporation.
• Preservatives also destabilise the tear film
• Worsens pre-existing dry eye.
• Surgical treatment failure in patients treated over the long term
with glaucoma eye drops.
• A prospective epidemiological survey was carried out in 1999.
All symptoms were more prevalent with P (Preservative) than
with PF (Preservative Free) eye drops :
– discomfort upon instillation (43 % versus 17 %)
– symptoms between instillations such as
burning-stinging (40 % versus 22 %)
– foreign body sensation (31 % versus 14 %)
– dry eye sensation (23 % versus 14 %)
– tearing (21 % versus 14 %)
– eyelid itching (18 % versus 10 %)
– An increased incidence (>2 times) of
ocular signs was seen with P eye drops.
PG
TEAR SHEET
332 Kerala Journal of Ophthalmology Vol. XXI, No. 3
Dry eye symptoms with beta blockers
• The most common ocular complaints - transient stinging andburning.
• Other commonly reported symptoms
– Transient blurred vision
– Reversible myopia
– Foreign body sensation
– Photophobia, itching
– Ocular irritation
– Cystoid macular edema
• Objective ocular signs:
– superficial punctate keratatis
– keratitis sicca
– corneal hypoesthesia
– lid ptosis and
– allergic blepharoconjunctivitis
Dry eye symptoms with beta blockers
• Timolol, timolol maleate, and benzalkonium chloride (BAK -0 01 %) are used worldwide for lowering intraocular pressure.
• The mean tear turnover using timolol + BAK was significantlylower (32 %) than the value of healthy controls in the study byKuppens et al.
• 50 % of Patients complained of burning or dry eye sensationwhen using Timolol + BAK.Basal tear turnover, intraocular pressure, and tear- film breakup time
Tear IOP Mean Number of subjectsturnover (SD) with tearfilm
Mean (SD) (mmHg) break up time(%/min)
< 10 > 10seconds seconds
Patients* when 10-7 17-7 4 16using timolol + (3-0) (2-0)BAK 13-2 18-1 5 15
Patients* when using (5-1) (3 0)timolol-BAK Healthy 15-7 14-7 0 2controls (5 3) (2 9)
Ocular complications with prostaglandin analogs
• Hypotensive lipids, named as eicosanoids, include latanoprost,travoprost and bimatoprost.
• Ocular side effects:– hyperemia– foreign body sensation– hypertrichosis– increased lower eyelid pigmentation with darkening of the
periocular skin and “cernes”– and superficial punctate keratopathy
• Allergic reactions occur in 1% of adult patients.
• It can also cause increased eyelash thickness, length and number.
• Can also cause permanent hyperchromia of the iris.
Dry eye symptoms with Prostaglandin analogues
• Prostaglandin Analogues may affect corneal sensitivity.
• Kozobolis VP et al examined that central corneal mechanicalsensitivity (CCMS) significantly reduced at the 5 minute intervalfor all analogs.
• The overall reduction in CCMS score at the 5-minute intervalsignificantly correlated with Schirmer and BUT tests scores.
• Latanoprost caused highest reduction in CCMS, followed byTravoprost
• Bimatoprost caused least reduction in CCMS
• Administration of ar tificial tears in combination withprostaglandin analogs may therefore be considered
Dry eye symptoms with alpha adrenergic agonists
• Apraclonidine and Brimonidine.
• Allergy has been reported in 4 to 26 % of patients.
• Eyedrop allergy and reduction of the tear film production is morecommon with brimonidine.
• Ocular Side effects:
– Rebound hyperemia
– Lid elevation
– Pupil dilatation (for apraclonidine)
– Allergy (up to 26 % for brimonidine, up to 36 % for apraclonidine)
– Uveitis ± allergic conjunctivitis ± IOP increase (brimonidine)
– Conjunctive hyperemia (for apraclonidine, 12.6 %)
– Itching and foreign body sensation (apraclonidine, 6.8 %)
– Tearing (apraclonidine, 4.5 %)
Dry eye symptoms with Carbonic anhydrase inhibitors
• Dorzolamide and brinzolamide.
• Dorzolamide is known to induce stinging and burning uponinstillation in more than one-third of patients.
• For both drugs, allergic reactions may be seen.
• Corneal decompensation may occur in patients with alreadycompromised endothelium and pre-existing corneal edema.
Compiled by
Dr. Sonia Rani John
Other signs of ocular surface damage reported more frequently
in patients treated with Containing Preservaties eye drops:
Presence of conjunctival signs 49% 26 %*Conjunctival redness 41% 20 %*Conjunctival follicles 22% 11 %*Fluorescein staining in the nasal bulbar conjunctiva 13% 5 %*Presence of an SPK 19% 9 %*Superficial punctate keratitisMild 17% 8.9 %*Severe 2% 0.6 %*Presence of at least one palpebral sign 22% 9 %*Anterior blepharitis 16% 7 %*Posterior blepharitis (meibomiitis) 7% 3 %*Eczema 6% 1 %*
September 2009 Kerala Journal of Ophthalmology 333
GENERAL INSTRUCTIONS TO AUTHORS
The Kerala Journal of Ophthalmology (KJO) is a quarterly; peer reviewed one, devoted to dissemination
of the latest in ophthalmology to the general ophthalmologists as well as to specialists in the various
subspecialties of this discipline. It invites submission of original work dealing with clinical and laboratory
materials.
Authors submitting materials to this journal are requested to adhere STRICTLY to the norms laid down
below. The matter must be typed on one side of the paper. A margin of I” must be left all around and the
material must be double-spaced. A page should contain not more than 25 lines. Two copies of the text in
paper and one copy in a CD must be submitted to the Editor and the corresponding author is advised to
keep another copy with him. The corresponding author must give it in writing in his covering letter that
the same matter will not be submitted elsewhere if accepted. He must also enclose the copyright transfer
of his work to this journal. The papers sent will be subjected to peer review. The accepted manuscripts
become the permanent property of this Journal. The author is informed that, if his work is returned to him
for correction / clarification after peer review, he should effect the same and send the manuscript back to
the Editor within one month. Each manuscript component mentioned here under must begin with a new
page and the pages are to be numbered at the right tip corner starting from the Title page.
1. TITLE: The title of the work must be brief and precise. It should not exceed two lines and 40 characters
(including comma, period) Author (s) full name (s) must be given along with his (their) degree and
the affiliations. Corresponding author’s name, correct address (including e-mail and Fax, if available)
and phone number must be mentioned at the bottom left hand corner of the first page.
2. ABSTRACT: The abstract is to be given in the beginning itself. It should not exceed 200 words. It must
contain the aim, methodology, results and conclusion. For case report, summary / conclusion alone is
to be given.
KEY WORDS (maximum five) in capitals are to be included at the end of Abstract.
3. INTRODUCTION: Describe the aim of the study, along with the hypotheses that were tested. Only
necessary references are to be given
4. METHOD: Give in detail the materials used and the methods employed. Describe the type of study.
Pharmacological names only must be mentioned for the drugs used and, if proprietary name is used,
then the manufacturers name must be given in parentheses. Except for standard, well-accepted
abbreviations (Including SI Units), all others must be introduced in parentheses when the full term is
used for the first time in the article.
5. RESULTS: Give only the results obtained by the study under discussion. State the statistics in the
correct scientific form (P value, mean etc). Results based on assumptions must not be given. Indicate
in the text the place where the tables have to be inserted
6. DISCUSSION: The discussion should be to the point and relevant to the subject under discussion.
This section can be combined with the previous one if the author desires. Avoid speculations. Use
only standard abbreviations or the abbreviations already introduced.
7. ACKNOWLEDGEMENT: This is to be made only to those who were directly and scientifically involved
with the preparation of the paper. Permitting authorities, technicians, photographers who assisted in
the work need not be mentioned.
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8. REFERENCES: The references should be given in numerical order in which they first appear in text
and not in alphabetical order (Citation Order System). It should be numbered consecutively in the
text. The references will not be checked by the Editor or by the Peer reviewer and hence the author is
solely responsible for its completeness and the accuracy. Period should not be employed anywhere in
the references. Personal communication, unpublished data and poster references, if mentioned, should
be in the text itself and the source mentioned in parentheses. References should be in the following
form:-
Journal reference: Author(s) full title, Journal name (as abbreviated in Index Medicus), volume number,
pages and year. If there are more than three authors, then mention the first three authors and then ‘et
al’.
Book reference: Authors(s) (& Editor, if any), title of book (and chapter), publisher, place of publication,
page number (s) of the cited portion and year.
9. THE LEGEND: The legend for the illustrations (and tables, if necessary) must be given in a separate
sheet of paper and should be typed double-spaced.
Illustrations: The photos and figures should be prepared in glossy prints with good contrast and of the
size 6” x 4”. Only salient details should be included. On the back of the illustration, the figure number
in text, title of the paper, the first author’s name and the top side (marked with an arrow) must be
specified. Except for arrows, no text is to be on the photos. It is the duty of the author(s) to get the
patient’s written permission when the subject is identifiable in the photo. Submit two sets of illustrations.
Illustrations from other Journals and books are usually not accepted. If used, it rests with the author(s)
to get the copy right permission from the original author / publisher and this permission letter must
be sent to the Editor at the time of submitting the manuscript. For Histological figures the stain and
magnification used should be noted e.g.: - H & E Stain x 70.
10. TABLE: It should be in double space. Each table must have an Arabic numeral (except for single
table) and a title both in a single line. Each column in the table must have a short heading. If a table
is large, then it must be continued in a second page, which also must have the table number and the
title. Avoid vertical lines in the tables. Two sets must be submitted.
The manuscripts are to be sent to The Editor by Courier Mail or by Registered post. The corresponding
author will receive communication from the Editor within two weeks of receiving the manuscript.
11. All manuscripts are subjected to editorial board review.
12. Other Categories of Manuscript
a) Original Articles should generally not exceed 3,000 words or 12 double – spaced pages.
b) Review Articles: can be on topics of relevance to clinical practice, research methodology, community
ophthalmology or investigative work, of relevance to visual science. These articles should include
up to date review of existing literature, and summarize the current status / preferred practice for
that particular topic.
Brief reports are short communication of new instruments, new laboratory techniques or surgical
techniques as well as interesting case reports with unique findings. These should not exceed 1000
words with a maximum of 2 illustrations. They should follow the format - introduction, case, and
discussion. No more than 8 references should be cited. Each brief report must begin with a 75-100
word summary that highlights the significance of the articles.
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